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Australasia has the highest rates of melanoma worldwide.1 In New Zealand, melanoma is the fourth most common cancer and sixth most common cancer resulting in death.2 In 2016, there were 216 cases of malignant melanomas diagnosed within Auckland District Health Board (DHB), which is an increase from 164 in 2014.2 Importantly, this does not capture in-situ melanomas, which have an incidence almost equal to that of invasive melanomas.3 As melanoma survival is strongly linked to its thickness and depth of invasion, morbidity and mortality can be reduced by both earlier and improved accuracy of diagnosis and improved access to specialist treatment.4 Confronted with increasing demands, the optimal model of healthcare delivery must be one that is efficient, cost effective and which provides patients with timely treatment.

In Auckland DHB prior to 2018, there were varied care pathways for patients referred for pigmented lesions suspected of being melanomas. Those referred to dermatology attended a first specialist assessment (FSA) with a dermatologist and, if necessary, returned for a second appointment for an excisional biopsy. If the lesion were proven to be a melanoma, these patients would return for a third appointment for wide local excision (WLE). A select group were also required to wait for an additional FSA with general surgery to discuss sentinel lymph node biopsy (SNB). Alternatively, patients were referred directly to general surgery and progressed through a similar step-wise process of multiple waiting lists and appointments, which added to delays in their diagnosis and treatment. Whichever specialty the patients attended was at the discretion of their referrer.

In 2018, dermatology and general surgery pooled their resources together to establish a novel multidisciplinary Pigmented Lesion Clinic (PLC) at Auckland DHB - the only one of its kind in New Zealand. The PLC is modelled on a ‘see and treat’ service, where patients referred for a suspected melanoma attend their FSA with dermatology and/or general surgery, and are offered excisional biopsy at the same appointment. Full skin checks are performed on this high-risk population, which is further complemented by support and education provided by a clinical nurse specialist. If required, patients return to the same clinic to discuss SNB. Otherwise, those with confirmed melanomas proceed directly to WLE. Thus, the treatment of melanomas is streamlined to as few as two appointments.

Similar models have been employed overseas for both pigmented lesions and non-melanoma skin cancers, with enhanced outcomes across multiple facets, including patient satisfaction, waiting time, tumour thickness and overall survival.5–7 We hypothesise that the multidisciplinary PLC will unify the treatment of melanoma within Auckland DHB into one service that enhances timely access to specialist assessment, accuracy of diagnosis and overall quality of care.

Method

All patients who attended the PLC between 1 March 2019 and 31 August 2019, for either suspected primary melanomas or further management of biopsy-proven melanomas, were included in the study. Both melanoma in-situ and malignant melanomas were analysed. Clinical records were reviewed to collect demographic, clinical and histopathological information. This included waiting times from referral through to wide local excision, performance of full skin check, delivery of skin cancer prevention education, clinical and histological diagnosis, benign-to-malignant ratio and Breslow thickness.

To assess the impact of PLC on melanoma diagnosis and treatment outcomes, a retrospective review of patients referred for suspected primary melanomas or further management of biopsy-proven melanomas in 2016 was performed to serve as comparison. Specifically, the same parameters were collected from clinical records of these patients referred to either dermatology or general surgery at Auckland DHB during the corresponding time period of 1 March 2016 to 31 August 2016.

Statistical analysis was performed using SPSS version 22. Chi-square analyses were used to test for significant differences in categorical variables. One-way ANOVA was used to demonstrate significant difference in mean waiting times. A p-value of <0.05 was considered statistically significant.

Institutional approval was granted by the Auckland DHB Research Review Committee (A+ 8431).

Results

In total, 251 patients attended the PLC for their FSA between 1 March and 31 August 2019. By comparison, 148 patients were referred for FSA with either dermatology or general surgery for suspected or biopsy-proven melanomas during the corresponding period in 2016.

Demographic variables are presented in Table 1. There were no significant differences between the PLC and retrospective cohort in regards to gender (43.8% male vs 48.6% male) and mean age (57.4 years vs 56.7 years). The majority of patients were of European descent (77.2% vs 80.4%).

Table 1: Demographics of patients with suspected or biopsy-proven melanomas referred to Auckland DHB in 2016 and 2019.

Patients attending the PLC were referred for 278 pigmented lesions (range 1–4), compared to 157 (range 1–4) in 2016. General practitioners (GPs) were the main referral source (95.7% vs 98.7%). Suspected melanomas accounted for the majority of referral indication (85.6% vs 96.2%), with an increase in patients referred for further management of pigmented lesions already biopsied by their GPs (14.4% vs 3.8%).

Treatment outcomes for the retrospective cohort in 2016, stratified by specialty, are presented in Table 2. Depending on whether patients were referred to dermatology or general surgery, there were significant differences in the mean waiting time to attend FSA (37 days vs 26 days, p=0.002), the proportion of pigmented lesions that required biopsy (48.4% vs 88.7%, p<0.001) and the number of patients who received full skin checks (80.4% vs 3.6%, p<0.001). The benign-to-malignant ratios were 1.6:1 and 3.2:1 for dermatology and general surgery, respectively.

Table 2: Treatment outcomes for patients with suspected or biopsy-proven melanomas referred to dermatology (92 patients with 95 lesions) and general surgery (56 patients with 62 lesions) at Auckland DHB in 2016.

A comparison of clinical and histological information between patients attending PLC and patients in 2016 is presented in Table 3. The PLC had a significantly reduced mean waiting time from referral to attending FSA (20 days vs 34 days, p<0.001) and from referral to biopsy where needed (36 days vs 57 days, p<0.001). The proportion of pigmented lesions biopsied at the same appointment as FSA increased (70.4% vs 6.9%, p<0.001), while the proportion of lesions requiring biopsy significantly reduced (35.2% vs 64.3%, p<0.001). The benign-to-malignant ratios were 2.4:1 and 2.3:1 for patients who attended PLC and patients in 2016, respectively.

Table 3: Features of care pathway and histology of patients referred with suspected or biopsy-proven melanomas in 2016 and PLC.

MM: malignant melanoma; MIS: melanoma in-situ.

There was an increase in the proportion of patients receiving full skin checks in the PLC (86.5% vs 51.4%, p<0.001), from which it was found that 1-in-5.3 patients had additional skin malignancies. Skin cancer prevention and self-skin examination education was imparted by the clinical nurse specialist to 51 patients.

There were 53 melanomas treated through the PLC, compared to 28 during the same time period in 2016 (Table 4). They were similar in gender (52.8% male vs 50% male), mean age (63.5 years and 64.9 years) and proportion of in-situ melanomas (47.2% vs 46.4%). Of the invasive melanomas, no significant difference was noted in mean Breslow thickness (0.96mm vs 0.93mm). The PLC had significantly shortened mean waiting times from referral to attending FSA (22.6 days vs 35.1 days, p=0.038), from FSA to excisional biopsy (2.2 days vs 21.3 days, p<0.001) and from referral to completion of treatment (50.6 days vs 99.1 days, p<0.001).

Notably, 35 of the melanomas treated through the PLC were referred with biopsy results available, which is an increase from 6 in 2016. These were excluded from our analysis of the waiting time between referral and biopsy. There was a significant difference in mean waiting time from referral to completion of treatment for melanomas referred with biopsy results available, compared to those that were referred for clinical assessment (59.9 days vs 38.3 days, p<0.001). Both remained significantly shorter than the corresponding 99.1 days in 2016.

Table 4: Clinical and histologic features of melanomas referred to Auckland DHB in 2016 and 2019.

Discussion

In this study, the PLC at Auckland DHB has been shown to enhance the diagnosis and treatment of melanomas on multiple fronts. Importantly, the retrospective analysis has highlighted a disparity in care that was previously provided to patients with pigmented lesions, depending on the specialty they had been referred to. By establishing a multidisciplinary clinic run jointly by dermatology and general surgery, Auckland DHB unified the melanoma patient pathway to ensure there is a single and equitable cancer pathway for all Auckland DHB melanoma patients.

Of the 238 lesions referred by GPs to the PLC as suspected melanomas, only 35.2% proceeded to an excisional biopsy. This proportion is further reduced from 2016, when 48.4% of suspicious pigmented lesions reviewed by dermatologists, and 88.7% reviewed by general surgeons, required an excisional biopsy. These figures highlight not only the enhanced diagnostic accuracy of the PLC, but also the important role a dermatologist plays in the diagnosis of pigmented lesions to minimise unnecessary surgery. Previously published rates of concordance in clinical diagnoses between GPs and dermatologists have varied between 42% and 54%.8,9 The lower concordance seen through PLC may be accounted for by a heightened index of suspicion from GPs given the high incidence of melanoma in New Zealand, which contrasts against the trained use of dermatoscopy by the supervising dermatologists with whom the general surgeons can collaborate—dermatoscopy being an invaluable tool in correctly separating melanomas from benign pigmented lesions.10

The diagnostic accuracy of the PLC is further evidenced by the benign-to-malignant ratio of 2.4:1. This compares very favourably to internationally published figures, which range from 4 to 14 for dermatologists and 20 to 40 for GPs.11 Maintaining a similar benign-to-malignant ratio from 2016 (2.3:1) through to PLC, while reducing the proportion of lesions being biopsied, represents the striking of an ideal balance between performing too many unnecessary biopsies and performing too few biopsies at the risk of missing a melanoma. To mitigate the risk of the latter, the PLC allows for clinical follow-up of patients to monitor for evolution or stability, if it is required, and provides all discharged patients with information regarding self-skin examination, and that any changing pigmented lesion warrants a further review with their GP. The reduction in unnecessary surgery improves the efficiency of the service and makes available otherwise expended resources, such as surgical appointments, to enable faster access to WLE for patients with confirmed melanomas. Ultimately, this translates into reduced patient morbidity and reduced resource wastage while achieving both time and monetary cost savings.

Establishment of the PLC and its ‘see and treat’ model has led to significant reductions in waiting time for patients to attend their FSA, to undergo excisional biopsy when there is clinical suspicion and to complete treatment with WLE when melanoma is confirmed. Rapid-access clinics dedicated to pigmented lesions in England and Ireland have similarly led to a reduction in treatment times and consequent reductions in tumour thickness and improved overall survival, though this was not observed in our study.5,12 In a New Zealand context, delivery of a see-and-treat clinic for skin lesions was first described by McGeoch et al as a coordinated service between GPs and plastic surgeons in Canterbury.13 This, and data from overseas see-and-treat clinics for non-melanoma skin cancers, have also reported reduced waiting times, as well as an enhanced perception of convenience and overall satisfaction.6,7 The benefits of the timely access to FSA and treatment are further compounded by enhanced compliance to the Ministry of Health’s 62-day target for faster cancer treatment.14 Whereas this target stipulates initiation of treatment within 62 days of receiving a high suspicion of cancer referral, patients treated through PLC had initiation of their treatment (WLE) on average 50.6 days after the referral date. For melanoma in-situ and early stage invasive melanomas not requiring adjuvant immunotherapy or radiation therapy, surgical excision (WLE) also represents completion of their treatment.

The advantages of the PLC model are not limited to enhanced diagnostic accuracy and timely access to treatment. The multidisciplinary model allows inter-specialty collaboration, which has led to improved outcomes in other tumour streams.15,16 Collaboration between dermatology and general surgery allows all patients to have ready access to services provided by general surgery, including surgery under general anaesthetics where required and SNB, without having to undergo previous external referral pathways. There were too few patients requiring SNB in the retrospective cohort to produce meaningful comparison. The clinical nurse specialist plays a key role in patient education, as well as being the point of contact and breaking bad news. The incorporation of a full skin exam as a standard of care has led to initiation of treatment for otherwise undetected skin malignancies in approximately one out of five patients. The importance of total body examination, rather than focusing only on the referred index lesion, has been highlighted previously by a UK study of over 1,800 patients, in which over one third of melanomas are detected as incidental lesions when the patient was referred for a separate and often benign lesion.17

Notably, 28 invasive melanomas over a six month period represent a small proportion of melanomas occurring within Auckland DHB. In 2016, there were 216 new melanomas reported within the same geographic area. Correspondingly, an Australian study has previously shown that only 20% of melanoma patients are reviewed by dermatologists, with a significant proportion treated by combination of GPs and surgeons.18 The PLC thus appears to be under-utilised. Increased awareness of the PLC among GPs may increase patient access to this publicly funded service.

In summary, a multidisciplinary approach between dermatology and general surgery, which incorporates dermatoscopic assessment of pigmented lesions, has led to enhanced diagnostic accuracy and a reduction in unnecessary surgeries. The development of a single pathway within Auckland DHB, combined with a see-and-treat approach, has led to significant reductions in waiting times for FSA, excisional biopsies and WLE. Other secondary and tertiary centres in New Zealand may also consider adopting this novel model of care, shown here to enhance multiple facets of melanoma diagnosis and treatment outcomes.

Summary

Abstract

AIM:  To investigate the outcomes and effect of a multidisciplinary ‘see and treat’ pigmented lesion clinic, run jointly by dermatology and general surgery, on the diagnosis and treatment of melanoma at Auckland District Health Board (DHB). METHOD: All patients attending the newly established Pigmented Lesion Clinic (PLC) between 1 March 2019 and 31 August 2019 were included in the study. They were compared against a retrospective cohort of patients seen for suspected or biopsy-proven melanomas during the same corresponding period in 2016. RESULTS: 251 new patients attended the PLC, compared to 148 new patients seen at Auckland DHB in 2016. There was a significant reduction in proportion of pigmented lesions requiring biopsy (35.2% vs 64.3%, p<0.001), with a benign-to-malignant ratio of 2.4:1. Fifty-three melanomas were treated through the PLC, with a significant reduction in mean waiting time from referral to first specialist assessment (22.6 vs 35.1 days, p=0.038), and from referral to wide local excision (50.6 vs 99.1 days, p<0.001). 86.5% of patients received full skin check, from which additional skin malignancies were detected in 1-per-5.3 patients. CONCLUSION: The novel PLC model has led to reduction in unnecessary excisional biopsies of benign pigmented lesions, while streamlining and improving timely access to specialist review and surgical treatment for patients with melanomas.

Aim

Method

Results

Conclusion

Author Information

Ken H-K Ip: Registrar, Dermatology Department, Auckland District Health Board, Auckland. Aravind Chandran: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland. Isaac Cranshaw: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Alex Ng: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Ann Giles: Clinical Nurse Specialist, Dermatology Department, Auckland District Health Board, Auckland. Karen Agnew: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland.

Acknowledgements

Correspondence

Karen Agnew, Dermatology Department, Auckland District Health Board, Greenlane Clinical Centre, 214 Greenlane West, Epsom, Auckland 1051, +64 9 307 4949 ext 26132

Correspondence Email

KAgnew@adhb.govt.nz

Competing Interests

Nil.

1. Jones WO, Harman CR, Ng AK, Shaw JH. Incidence of malignant melanoma in Auckland, New Zealand: highest rates in the world. World journal of surgery. 1999;23:732-5.

2. New Zealand Ministry of Health. New Cancer Registrations 2016. Available from: https://www.health.govt.nz/publication/new-cancer-registrations-2016 [accessed 18 November 2019]

3. Elwood JM, Kim SJ, Ip KH, et al. In situ and invasive melanoma in a high‐risk, New Zealand, population: A population‐based study. Australasian Journal of Dermatology. 2019;60:38-444.

4. Balch CM. Cutaneous melanoma: prognosis and treatment results worldwide. Seminars in surgical oncology. 1992;8:400-414

5. Pacifico MD, Pearl RA, Grover R. The UK Government two-week rule and its impact on melanoma prognosis: an evidence-based study. The Annals of The Royal College of Surgeons of England. 2007;89:609-15.

6. van der Geer S, Frunt M, Romero HL, et al. One‐stop‐shop treatment for basal cell carcinoma, part of a new disease management strategy. Journal of the European Academy of Dermatology and Venereology. 2012;26:1154-7.

7. Salam MA, Matai V, Salhab M, Hilger AW. The facial skin lesions “see and treat” clinic: a prospective study. European Archives of Oto-Rhino-Laryngology and Head & Neck. 2006;263:764-6.

8. Tran H, Chen K, Lim AC, et al. Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists. Australasian Journal of Dermatology. 2005;46:230-4.

9. Morrison A, O'Loughlin S, Powell FC. Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients. International journal of dermatology. 2001;40:104-7.

10. Vestergaard ME, Macaskill PH, Holt PE, Menzies SW. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta‐analysis of studies performed in a clinical setting. British Journal of Dermatology. 2008;159:669-76.

11. Sidhu S, Bodger O, Williams N, Roberts DL. The number of benign moles excised for each malignant melanoma: the number needed to treat. Clinical and Experimental Dermatology. 2012;37:6-9.

12. Lynch M, Tierney E, Roche L, et al. Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland. Irish Journal of Medical Science. 2017;186:671-5.

13. McGeoch G, Sycamore M, Shand B, Simcock J. A regional programme to improve skin cancer management. Journal of primary health care. 2015;7:339-44.

14. New Zealand Ministry of Health. Faster Cancer Treatment. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/national-cancer-programme/cancer-initiatives/faster-cancer-treatment [accessed 18 November 2019]

15. Dey P, Dixon JM, Bundred N, et al. Costs and benefits of a one stop clinic compared with a dedicated breast clinic: randomised controlled trial. BMJ. 2002;324:507-10.

16. Shah J. Assessment of activity and outcome from a one-stop clinic for men with suspected prostate cancer: Five years’ experience. Journal of Clinical Urology. 2016;9:5-10.

17. Aldridge RB, Naysmith L, Ooi ET, et al. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta dermato-venereologica. 2013;93:689-92.

18. Baade PD, Youl PH, English DR, et al. Clinical pathways to diagnose melanoma: a population-based study. Melanoma Research. 2007;17:243-9.

Contact diana@nzma.org.nz
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Australasia has the highest rates of melanoma worldwide.1 In New Zealand, melanoma is the fourth most common cancer and sixth most common cancer resulting in death.2 In 2016, there were 216 cases of malignant melanomas diagnosed within Auckland District Health Board (DHB), which is an increase from 164 in 2014.2 Importantly, this does not capture in-situ melanomas, which have an incidence almost equal to that of invasive melanomas.3 As melanoma survival is strongly linked to its thickness and depth of invasion, morbidity and mortality can be reduced by both earlier and improved accuracy of diagnosis and improved access to specialist treatment.4 Confronted with increasing demands, the optimal model of healthcare delivery must be one that is efficient, cost effective and which provides patients with timely treatment.

In Auckland DHB prior to 2018, there were varied care pathways for patients referred for pigmented lesions suspected of being melanomas. Those referred to dermatology attended a first specialist assessment (FSA) with a dermatologist and, if necessary, returned for a second appointment for an excisional biopsy. If the lesion were proven to be a melanoma, these patients would return for a third appointment for wide local excision (WLE). A select group were also required to wait for an additional FSA with general surgery to discuss sentinel lymph node biopsy (SNB). Alternatively, patients were referred directly to general surgery and progressed through a similar step-wise process of multiple waiting lists and appointments, which added to delays in their diagnosis and treatment. Whichever specialty the patients attended was at the discretion of their referrer.

In 2018, dermatology and general surgery pooled their resources together to establish a novel multidisciplinary Pigmented Lesion Clinic (PLC) at Auckland DHB - the only one of its kind in New Zealand. The PLC is modelled on a ‘see and treat’ service, where patients referred for a suspected melanoma attend their FSA with dermatology and/or general surgery, and are offered excisional biopsy at the same appointment. Full skin checks are performed on this high-risk population, which is further complemented by support and education provided by a clinical nurse specialist. If required, patients return to the same clinic to discuss SNB. Otherwise, those with confirmed melanomas proceed directly to WLE. Thus, the treatment of melanomas is streamlined to as few as two appointments.

Similar models have been employed overseas for both pigmented lesions and non-melanoma skin cancers, with enhanced outcomes across multiple facets, including patient satisfaction, waiting time, tumour thickness and overall survival.5–7 We hypothesise that the multidisciplinary PLC will unify the treatment of melanoma within Auckland DHB into one service that enhances timely access to specialist assessment, accuracy of diagnosis and overall quality of care.

Method

All patients who attended the PLC between 1 March 2019 and 31 August 2019, for either suspected primary melanomas or further management of biopsy-proven melanomas, were included in the study. Both melanoma in-situ and malignant melanomas were analysed. Clinical records were reviewed to collect demographic, clinical and histopathological information. This included waiting times from referral through to wide local excision, performance of full skin check, delivery of skin cancer prevention education, clinical and histological diagnosis, benign-to-malignant ratio and Breslow thickness.

To assess the impact of PLC on melanoma diagnosis and treatment outcomes, a retrospective review of patients referred for suspected primary melanomas or further management of biopsy-proven melanomas in 2016 was performed to serve as comparison. Specifically, the same parameters were collected from clinical records of these patients referred to either dermatology or general surgery at Auckland DHB during the corresponding time period of 1 March 2016 to 31 August 2016.

Statistical analysis was performed using SPSS version 22. Chi-square analyses were used to test for significant differences in categorical variables. One-way ANOVA was used to demonstrate significant difference in mean waiting times. A p-value of <0.05 was considered statistically significant.

Institutional approval was granted by the Auckland DHB Research Review Committee (A+ 8431).

Results

In total, 251 patients attended the PLC for their FSA between 1 March and 31 August 2019. By comparison, 148 patients were referred for FSA with either dermatology or general surgery for suspected or biopsy-proven melanomas during the corresponding period in 2016.

Demographic variables are presented in Table 1. There were no significant differences between the PLC and retrospective cohort in regards to gender (43.8% male vs 48.6% male) and mean age (57.4 years vs 56.7 years). The majority of patients were of European descent (77.2% vs 80.4%).

Table 1: Demographics of patients with suspected or biopsy-proven melanomas referred to Auckland DHB in 2016 and 2019.

Patients attending the PLC were referred for 278 pigmented lesions (range 1–4), compared to 157 (range 1–4) in 2016. General practitioners (GPs) were the main referral source (95.7% vs 98.7%). Suspected melanomas accounted for the majority of referral indication (85.6% vs 96.2%), with an increase in patients referred for further management of pigmented lesions already biopsied by their GPs (14.4% vs 3.8%).

Treatment outcomes for the retrospective cohort in 2016, stratified by specialty, are presented in Table 2. Depending on whether patients were referred to dermatology or general surgery, there were significant differences in the mean waiting time to attend FSA (37 days vs 26 days, p=0.002), the proportion of pigmented lesions that required biopsy (48.4% vs 88.7%, p<0.001) and the number of patients who received full skin checks (80.4% vs 3.6%, p<0.001). The benign-to-malignant ratios were 1.6:1 and 3.2:1 for dermatology and general surgery, respectively.

Table 2: Treatment outcomes for patients with suspected or biopsy-proven melanomas referred to dermatology (92 patients with 95 lesions) and general surgery (56 patients with 62 lesions) at Auckland DHB in 2016.

A comparison of clinical and histological information between patients attending PLC and patients in 2016 is presented in Table 3. The PLC had a significantly reduced mean waiting time from referral to attending FSA (20 days vs 34 days, p<0.001) and from referral to biopsy where needed (36 days vs 57 days, p<0.001). The proportion of pigmented lesions biopsied at the same appointment as FSA increased (70.4% vs 6.9%, p<0.001), while the proportion of lesions requiring biopsy significantly reduced (35.2% vs 64.3%, p<0.001). The benign-to-malignant ratios were 2.4:1 and 2.3:1 for patients who attended PLC and patients in 2016, respectively.

Table 3: Features of care pathway and histology of patients referred with suspected or biopsy-proven melanomas in 2016 and PLC.

MM: malignant melanoma; MIS: melanoma in-situ.

There was an increase in the proportion of patients receiving full skin checks in the PLC (86.5% vs 51.4%, p<0.001), from which it was found that 1-in-5.3 patients had additional skin malignancies. Skin cancer prevention and self-skin examination education was imparted by the clinical nurse specialist to 51 patients.

There were 53 melanomas treated through the PLC, compared to 28 during the same time period in 2016 (Table 4). They were similar in gender (52.8% male vs 50% male), mean age (63.5 years and 64.9 years) and proportion of in-situ melanomas (47.2% vs 46.4%). Of the invasive melanomas, no significant difference was noted in mean Breslow thickness (0.96mm vs 0.93mm). The PLC had significantly shortened mean waiting times from referral to attending FSA (22.6 days vs 35.1 days, p=0.038), from FSA to excisional biopsy (2.2 days vs 21.3 days, p<0.001) and from referral to completion of treatment (50.6 days vs 99.1 days, p<0.001).

Notably, 35 of the melanomas treated through the PLC were referred with biopsy results available, which is an increase from 6 in 2016. These were excluded from our analysis of the waiting time between referral and biopsy. There was a significant difference in mean waiting time from referral to completion of treatment for melanomas referred with biopsy results available, compared to those that were referred for clinical assessment (59.9 days vs 38.3 days, p<0.001). Both remained significantly shorter than the corresponding 99.1 days in 2016.

Table 4: Clinical and histologic features of melanomas referred to Auckland DHB in 2016 and 2019.

Discussion

In this study, the PLC at Auckland DHB has been shown to enhance the diagnosis and treatment of melanomas on multiple fronts. Importantly, the retrospective analysis has highlighted a disparity in care that was previously provided to patients with pigmented lesions, depending on the specialty they had been referred to. By establishing a multidisciplinary clinic run jointly by dermatology and general surgery, Auckland DHB unified the melanoma patient pathway to ensure there is a single and equitable cancer pathway for all Auckland DHB melanoma patients.

Of the 238 lesions referred by GPs to the PLC as suspected melanomas, only 35.2% proceeded to an excisional biopsy. This proportion is further reduced from 2016, when 48.4% of suspicious pigmented lesions reviewed by dermatologists, and 88.7% reviewed by general surgeons, required an excisional biopsy. These figures highlight not only the enhanced diagnostic accuracy of the PLC, but also the important role a dermatologist plays in the diagnosis of pigmented lesions to minimise unnecessary surgery. Previously published rates of concordance in clinical diagnoses between GPs and dermatologists have varied between 42% and 54%.8,9 The lower concordance seen through PLC may be accounted for by a heightened index of suspicion from GPs given the high incidence of melanoma in New Zealand, which contrasts against the trained use of dermatoscopy by the supervising dermatologists with whom the general surgeons can collaborate—dermatoscopy being an invaluable tool in correctly separating melanomas from benign pigmented lesions.10

The diagnostic accuracy of the PLC is further evidenced by the benign-to-malignant ratio of 2.4:1. This compares very favourably to internationally published figures, which range from 4 to 14 for dermatologists and 20 to 40 for GPs.11 Maintaining a similar benign-to-malignant ratio from 2016 (2.3:1) through to PLC, while reducing the proportion of lesions being biopsied, represents the striking of an ideal balance between performing too many unnecessary biopsies and performing too few biopsies at the risk of missing a melanoma. To mitigate the risk of the latter, the PLC allows for clinical follow-up of patients to monitor for evolution or stability, if it is required, and provides all discharged patients with information regarding self-skin examination, and that any changing pigmented lesion warrants a further review with their GP. The reduction in unnecessary surgery improves the efficiency of the service and makes available otherwise expended resources, such as surgical appointments, to enable faster access to WLE for patients with confirmed melanomas. Ultimately, this translates into reduced patient morbidity and reduced resource wastage while achieving both time and monetary cost savings.

Establishment of the PLC and its ‘see and treat’ model has led to significant reductions in waiting time for patients to attend their FSA, to undergo excisional biopsy when there is clinical suspicion and to complete treatment with WLE when melanoma is confirmed. Rapid-access clinics dedicated to pigmented lesions in England and Ireland have similarly led to a reduction in treatment times and consequent reductions in tumour thickness and improved overall survival, though this was not observed in our study.5,12 In a New Zealand context, delivery of a see-and-treat clinic for skin lesions was first described by McGeoch et al as a coordinated service between GPs and plastic surgeons in Canterbury.13 This, and data from overseas see-and-treat clinics for non-melanoma skin cancers, have also reported reduced waiting times, as well as an enhanced perception of convenience and overall satisfaction.6,7 The benefits of the timely access to FSA and treatment are further compounded by enhanced compliance to the Ministry of Health’s 62-day target for faster cancer treatment.14 Whereas this target stipulates initiation of treatment within 62 days of receiving a high suspicion of cancer referral, patients treated through PLC had initiation of their treatment (WLE) on average 50.6 days after the referral date. For melanoma in-situ and early stage invasive melanomas not requiring adjuvant immunotherapy or radiation therapy, surgical excision (WLE) also represents completion of their treatment.

The advantages of the PLC model are not limited to enhanced diagnostic accuracy and timely access to treatment. The multidisciplinary model allows inter-specialty collaboration, which has led to improved outcomes in other tumour streams.15,16 Collaboration between dermatology and general surgery allows all patients to have ready access to services provided by general surgery, including surgery under general anaesthetics where required and SNB, without having to undergo previous external referral pathways. There were too few patients requiring SNB in the retrospective cohort to produce meaningful comparison. The clinical nurse specialist plays a key role in patient education, as well as being the point of contact and breaking bad news. The incorporation of a full skin exam as a standard of care has led to initiation of treatment for otherwise undetected skin malignancies in approximately one out of five patients. The importance of total body examination, rather than focusing only on the referred index lesion, has been highlighted previously by a UK study of over 1,800 patients, in which over one third of melanomas are detected as incidental lesions when the patient was referred for a separate and often benign lesion.17

Notably, 28 invasive melanomas over a six month period represent a small proportion of melanomas occurring within Auckland DHB. In 2016, there were 216 new melanomas reported within the same geographic area. Correspondingly, an Australian study has previously shown that only 20% of melanoma patients are reviewed by dermatologists, with a significant proportion treated by combination of GPs and surgeons.18 The PLC thus appears to be under-utilised. Increased awareness of the PLC among GPs may increase patient access to this publicly funded service.

In summary, a multidisciplinary approach between dermatology and general surgery, which incorporates dermatoscopic assessment of pigmented lesions, has led to enhanced diagnostic accuracy and a reduction in unnecessary surgeries. The development of a single pathway within Auckland DHB, combined with a see-and-treat approach, has led to significant reductions in waiting times for FSA, excisional biopsies and WLE. Other secondary and tertiary centres in New Zealand may also consider adopting this novel model of care, shown here to enhance multiple facets of melanoma diagnosis and treatment outcomes.

Summary

Abstract

AIM:  To investigate the outcomes and effect of a multidisciplinary ‘see and treat’ pigmented lesion clinic, run jointly by dermatology and general surgery, on the diagnosis and treatment of melanoma at Auckland District Health Board (DHB). METHOD: All patients attending the newly established Pigmented Lesion Clinic (PLC) between 1 March 2019 and 31 August 2019 were included in the study. They were compared against a retrospective cohort of patients seen for suspected or biopsy-proven melanomas during the same corresponding period in 2016. RESULTS: 251 new patients attended the PLC, compared to 148 new patients seen at Auckland DHB in 2016. There was a significant reduction in proportion of pigmented lesions requiring biopsy (35.2% vs 64.3%, p<0.001), with a benign-to-malignant ratio of 2.4:1. Fifty-three melanomas were treated through the PLC, with a significant reduction in mean waiting time from referral to first specialist assessment (22.6 vs 35.1 days, p=0.038), and from referral to wide local excision (50.6 vs 99.1 days, p<0.001). 86.5% of patients received full skin check, from which additional skin malignancies were detected in 1-per-5.3 patients. CONCLUSION: The novel PLC model has led to reduction in unnecessary excisional biopsies of benign pigmented lesions, while streamlining and improving timely access to specialist review and surgical treatment for patients with melanomas.

Aim

Method

Results

Conclusion

Author Information

Ken H-K Ip: Registrar, Dermatology Department, Auckland District Health Board, Auckland. Aravind Chandran: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland. Isaac Cranshaw: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Alex Ng: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Ann Giles: Clinical Nurse Specialist, Dermatology Department, Auckland District Health Board, Auckland. Karen Agnew: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland.

Acknowledgements

Correspondence

Karen Agnew, Dermatology Department, Auckland District Health Board, Greenlane Clinical Centre, 214 Greenlane West, Epsom, Auckland 1051, +64 9 307 4949 ext 26132

Correspondence Email

KAgnew@adhb.govt.nz

Competing Interests

Nil.

1. Jones WO, Harman CR, Ng AK, Shaw JH. Incidence of malignant melanoma in Auckland, New Zealand: highest rates in the world. World journal of surgery. 1999;23:732-5.

2. New Zealand Ministry of Health. New Cancer Registrations 2016. Available from: https://www.health.govt.nz/publication/new-cancer-registrations-2016 [accessed 18 November 2019]

3. Elwood JM, Kim SJ, Ip KH, et al. In situ and invasive melanoma in a high‐risk, New Zealand, population: A population‐based study. Australasian Journal of Dermatology. 2019;60:38-444.

4. Balch CM. Cutaneous melanoma: prognosis and treatment results worldwide. Seminars in surgical oncology. 1992;8:400-414

5. Pacifico MD, Pearl RA, Grover R. The UK Government two-week rule and its impact on melanoma prognosis: an evidence-based study. The Annals of The Royal College of Surgeons of England. 2007;89:609-15.

6. van der Geer S, Frunt M, Romero HL, et al. One‐stop‐shop treatment for basal cell carcinoma, part of a new disease management strategy. Journal of the European Academy of Dermatology and Venereology. 2012;26:1154-7.

7. Salam MA, Matai V, Salhab M, Hilger AW. The facial skin lesions “see and treat” clinic: a prospective study. European Archives of Oto-Rhino-Laryngology and Head & Neck. 2006;263:764-6.

8. Tran H, Chen K, Lim AC, et al. Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists. Australasian Journal of Dermatology. 2005;46:230-4.

9. Morrison A, O'Loughlin S, Powell FC. Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients. International journal of dermatology. 2001;40:104-7.

10. Vestergaard ME, Macaskill PH, Holt PE, Menzies SW. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta‐analysis of studies performed in a clinical setting. British Journal of Dermatology. 2008;159:669-76.

11. Sidhu S, Bodger O, Williams N, Roberts DL. The number of benign moles excised for each malignant melanoma: the number needed to treat. Clinical and Experimental Dermatology. 2012;37:6-9.

12. Lynch M, Tierney E, Roche L, et al. Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland. Irish Journal of Medical Science. 2017;186:671-5.

13. McGeoch G, Sycamore M, Shand B, Simcock J. A regional programme to improve skin cancer management. Journal of primary health care. 2015;7:339-44.

14. New Zealand Ministry of Health. Faster Cancer Treatment. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/national-cancer-programme/cancer-initiatives/faster-cancer-treatment [accessed 18 November 2019]

15. Dey P, Dixon JM, Bundred N, et al. Costs and benefits of a one stop clinic compared with a dedicated breast clinic: randomised controlled trial. BMJ. 2002;324:507-10.

16. Shah J. Assessment of activity and outcome from a one-stop clinic for men with suspected prostate cancer: Five years’ experience. Journal of Clinical Urology. 2016;9:5-10.

17. Aldridge RB, Naysmith L, Ooi ET, et al. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta dermato-venereologica. 2013;93:689-92.

18. Baade PD, Youl PH, English DR, et al. Clinical pathways to diagnose melanoma: a population-based study. Melanoma Research. 2007;17:243-9.

Contact diana@nzma.org.nz
for the PDF of this article

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Australasia has the highest rates of melanoma worldwide.1 In New Zealand, melanoma is the fourth most common cancer and sixth most common cancer resulting in death.2 In 2016, there were 216 cases of malignant melanomas diagnosed within Auckland District Health Board (DHB), which is an increase from 164 in 2014.2 Importantly, this does not capture in-situ melanomas, which have an incidence almost equal to that of invasive melanomas.3 As melanoma survival is strongly linked to its thickness and depth of invasion, morbidity and mortality can be reduced by both earlier and improved accuracy of diagnosis and improved access to specialist treatment.4 Confronted with increasing demands, the optimal model of healthcare delivery must be one that is efficient, cost effective and which provides patients with timely treatment.

In Auckland DHB prior to 2018, there were varied care pathways for patients referred for pigmented lesions suspected of being melanomas. Those referred to dermatology attended a first specialist assessment (FSA) with a dermatologist and, if necessary, returned for a second appointment for an excisional biopsy. If the lesion were proven to be a melanoma, these patients would return for a third appointment for wide local excision (WLE). A select group were also required to wait for an additional FSA with general surgery to discuss sentinel lymph node biopsy (SNB). Alternatively, patients were referred directly to general surgery and progressed through a similar step-wise process of multiple waiting lists and appointments, which added to delays in their diagnosis and treatment. Whichever specialty the patients attended was at the discretion of their referrer.

In 2018, dermatology and general surgery pooled their resources together to establish a novel multidisciplinary Pigmented Lesion Clinic (PLC) at Auckland DHB - the only one of its kind in New Zealand. The PLC is modelled on a ‘see and treat’ service, where patients referred for a suspected melanoma attend their FSA with dermatology and/or general surgery, and are offered excisional biopsy at the same appointment. Full skin checks are performed on this high-risk population, which is further complemented by support and education provided by a clinical nurse specialist. If required, patients return to the same clinic to discuss SNB. Otherwise, those with confirmed melanomas proceed directly to WLE. Thus, the treatment of melanomas is streamlined to as few as two appointments.

Similar models have been employed overseas for both pigmented lesions and non-melanoma skin cancers, with enhanced outcomes across multiple facets, including patient satisfaction, waiting time, tumour thickness and overall survival.5–7 We hypothesise that the multidisciplinary PLC will unify the treatment of melanoma within Auckland DHB into one service that enhances timely access to specialist assessment, accuracy of diagnosis and overall quality of care.

Method

All patients who attended the PLC between 1 March 2019 and 31 August 2019, for either suspected primary melanomas or further management of biopsy-proven melanomas, were included in the study. Both melanoma in-situ and malignant melanomas were analysed. Clinical records were reviewed to collect demographic, clinical and histopathological information. This included waiting times from referral through to wide local excision, performance of full skin check, delivery of skin cancer prevention education, clinical and histological diagnosis, benign-to-malignant ratio and Breslow thickness.

To assess the impact of PLC on melanoma diagnosis and treatment outcomes, a retrospective review of patients referred for suspected primary melanomas or further management of biopsy-proven melanomas in 2016 was performed to serve as comparison. Specifically, the same parameters were collected from clinical records of these patients referred to either dermatology or general surgery at Auckland DHB during the corresponding time period of 1 March 2016 to 31 August 2016.

Statistical analysis was performed using SPSS version 22. Chi-square analyses were used to test for significant differences in categorical variables. One-way ANOVA was used to demonstrate significant difference in mean waiting times. A p-value of <0.05 was considered statistically significant.

Institutional approval was granted by the Auckland DHB Research Review Committee (A+ 8431).

Results

In total, 251 patients attended the PLC for their FSA between 1 March and 31 August 2019. By comparison, 148 patients were referred for FSA with either dermatology or general surgery for suspected or biopsy-proven melanomas during the corresponding period in 2016.

Demographic variables are presented in Table 1. There were no significant differences between the PLC and retrospective cohort in regards to gender (43.8% male vs 48.6% male) and mean age (57.4 years vs 56.7 years). The majority of patients were of European descent (77.2% vs 80.4%).

Table 1: Demographics of patients with suspected or biopsy-proven melanomas referred to Auckland DHB in 2016 and 2019.

Patients attending the PLC were referred for 278 pigmented lesions (range 1–4), compared to 157 (range 1–4) in 2016. General practitioners (GPs) were the main referral source (95.7% vs 98.7%). Suspected melanomas accounted for the majority of referral indication (85.6% vs 96.2%), with an increase in patients referred for further management of pigmented lesions already biopsied by their GPs (14.4% vs 3.8%).

Treatment outcomes for the retrospective cohort in 2016, stratified by specialty, are presented in Table 2. Depending on whether patients were referred to dermatology or general surgery, there were significant differences in the mean waiting time to attend FSA (37 days vs 26 days, p=0.002), the proportion of pigmented lesions that required biopsy (48.4% vs 88.7%, p<0.001) and the number of patients who received full skin checks (80.4% vs 3.6%, p<0.001). The benign-to-malignant ratios were 1.6:1 and 3.2:1 for dermatology and general surgery, respectively.

Table 2: Treatment outcomes for patients with suspected or biopsy-proven melanomas referred to dermatology (92 patients with 95 lesions) and general surgery (56 patients with 62 lesions) at Auckland DHB in 2016.

A comparison of clinical and histological information between patients attending PLC and patients in 2016 is presented in Table 3. The PLC had a significantly reduced mean waiting time from referral to attending FSA (20 days vs 34 days, p<0.001) and from referral to biopsy where needed (36 days vs 57 days, p<0.001). The proportion of pigmented lesions biopsied at the same appointment as FSA increased (70.4% vs 6.9%, p<0.001), while the proportion of lesions requiring biopsy significantly reduced (35.2% vs 64.3%, p<0.001). The benign-to-malignant ratios were 2.4:1 and 2.3:1 for patients who attended PLC and patients in 2016, respectively.

Table 3: Features of care pathway and histology of patients referred with suspected or biopsy-proven melanomas in 2016 and PLC.

MM: malignant melanoma; MIS: melanoma in-situ.

There was an increase in the proportion of patients receiving full skin checks in the PLC (86.5% vs 51.4%, p<0.001), from which it was found that 1-in-5.3 patients had additional skin malignancies. Skin cancer prevention and self-skin examination education was imparted by the clinical nurse specialist to 51 patients.

There were 53 melanomas treated through the PLC, compared to 28 during the same time period in 2016 (Table 4). They were similar in gender (52.8% male vs 50% male), mean age (63.5 years and 64.9 years) and proportion of in-situ melanomas (47.2% vs 46.4%). Of the invasive melanomas, no significant difference was noted in mean Breslow thickness (0.96mm vs 0.93mm). The PLC had significantly shortened mean waiting times from referral to attending FSA (22.6 days vs 35.1 days, p=0.038), from FSA to excisional biopsy (2.2 days vs 21.3 days, p<0.001) and from referral to completion of treatment (50.6 days vs 99.1 days, p<0.001).

Notably, 35 of the melanomas treated through the PLC were referred with biopsy results available, which is an increase from 6 in 2016. These were excluded from our analysis of the waiting time between referral and biopsy. There was a significant difference in mean waiting time from referral to completion of treatment for melanomas referred with biopsy results available, compared to those that were referred for clinical assessment (59.9 days vs 38.3 days, p<0.001). Both remained significantly shorter than the corresponding 99.1 days in 2016.

Table 4: Clinical and histologic features of melanomas referred to Auckland DHB in 2016 and 2019.

Discussion

In this study, the PLC at Auckland DHB has been shown to enhance the diagnosis and treatment of melanomas on multiple fronts. Importantly, the retrospective analysis has highlighted a disparity in care that was previously provided to patients with pigmented lesions, depending on the specialty they had been referred to. By establishing a multidisciplinary clinic run jointly by dermatology and general surgery, Auckland DHB unified the melanoma patient pathway to ensure there is a single and equitable cancer pathway for all Auckland DHB melanoma patients.

Of the 238 lesions referred by GPs to the PLC as suspected melanomas, only 35.2% proceeded to an excisional biopsy. This proportion is further reduced from 2016, when 48.4% of suspicious pigmented lesions reviewed by dermatologists, and 88.7% reviewed by general surgeons, required an excisional biopsy. These figures highlight not only the enhanced diagnostic accuracy of the PLC, but also the important role a dermatologist plays in the diagnosis of pigmented lesions to minimise unnecessary surgery. Previously published rates of concordance in clinical diagnoses between GPs and dermatologists have varied between 42% and 54%.8,9 The lower concordance seen through PLC may be accounted for by a heightened index of suspicion from GPs given the high incidence of melanoma in New Zealand, which contrasts against the trained use of dermatoscopy by the supervising dermatologists with whom the general surgeons can collaborate—dermatoscopy being an invaluable tool in correctly separating melanomas from benign pigmented lesions.10

The diagnostic accuracy of the PLC is further evidenced by the benign-to-malignant ratio of 2.4:1. This compares very favourably to internationally published figures, which range from 4 to 14 for dermatologists and 20 to 40 for GPs.11 Maintaining a similar benign-to-malignant ratio from 2016 (2.3:1) through to PLC, while reducing the proportion of lesions being biopsied, represents the striking of an ideal balance between performing too many unnecessary biopsies and performing too few biopsies at the risk of missing a melanoma. To mitigate the risk of the latter, the PLC allows for clinical follow-up of patients to monitor for evolution or stability, if it is required, and provides all discharged patients with information regarding self-skin examination, and that any changing pigmented lesion warrants a further review with their GP. The reduction in unnecessary surgery improves the efficiency of the service and makes available otherwise expended resources, such as surgical appointments, to enable faster access to WLE for patients with confirmed melanomas. Ultimately, this translates into reduced patient morbidity and reduced resource wastage while achieving both time and monetary cost savings.

Establishment of the PLC and its ‘see and treat’ model has led to significant reductions in waiting time for patients to attend their FSA, to undergo excisional biopsy when there is clinical suspicion and to complete treatment with WLE when melanoma is confirmed. Rapid-access clinics dedicated to pigmented lesions in England and Ireland have similarly led to a reduction in treatment times and consequent reductions in tumour thickness and improved overall survival, though this was not observed in our study.5,12 In a New Zealand context, delivery of a see-and-treat clinic for skin lesions was first described by McGeoch et al as a coordinated service between GPs and plastic surgeons in Canterbury.13 This, and data from overseas see-and-treat clinics for non-melanoma skin cancers, have also reported reduced waiting times, as well as an enhanced perception of convenience and overall satisfaction.6,7 The benefits of the timely access to FSA and treatment are further compounded by enhanced compliance to the Ministry of Health’s 62-day target for faster cancer treatment.14 Whereas this target stipulates initiation of treatment within 62 days of receiving a high suspicion of cancer referral, patients treated through PLC had initiation of their treatment (WLE) on average 50.6 days after the referral date. For melanoma in-situ and early stage invasive melanomas not requiring adjuvant immunotherapy or radiation therapy, surgical excision (WLE) also represents completion of their treatment.

The advantages of the PLC model are not limited to enhanced diagnostic accuracy and timely access to treatment. The multidisciplinary model allows inter-specialty collaboration, which has led to improved outcomes in other tumour streams.15,16 Collaboration between dermatology and general surgery allows all patients to have ready access to services provided by general surgery, including surgery under general anaesthetics where required and SNB, without having to undergo previous external referral pathways. There were too few patients requiring SNB in the retrospective cohort to produce meaningful comparison. The clinical nurse specialist plays a key role in patient education, as well as being the point of contact and breaking bad news. The incorporation of a full skin exam as a standard of care has led to initiation of treatment for otherwise undetected skin malignancies in approximately one out of five patients. The importance of total body examination, rather than focusing only on the referred index lesion, has been highlighted previously by a UK study of over 1,800 patients, in which over one third of melanomas are detected as incidental lesions when the patient was referred for a separate and often benign lesion.17

Notably, 28 invasive melanomas over a six month period represent a small proportion of melanomas occurring within Auckland DHB. In 2016, there were 216 new melanomas reported within the same geographic area. Correspondingly, an Australian study has previously shown that only 20% of melanoma patients are reviewed by dermatologists, with a significant proportion treated by combination of GPs and surgeons.18 The PLC thus appears to be under-utilised. Increased awareness of the PLC among GPs may increase patient access to this publicly funded service.

In summary, a multidisciplinary approach between dermatology and general surgery, which incorporates dermatoscopic assessment of pigmented lesions, has led to enhanced diagnostic accuracy and a reduction in unnecessary surgeries. The development of a single pathway within Auckland DHB, combined with a see-and-treat approach, has led to significant reductions in waiting times for FSA, excisional biopsies and WLE. Other secondary and tertiary centres in New Zealand may also consider adopting this novel model of care, shown here to enhance multiple facets of melanoma diagnosis and treatment outcomes.

Summary

Abstract

AIM:  To investigate the outcomes and effect of a multidisciplinary ‘see and treat’ pigmented lesion clinic, run jointly by dermatology and general surgery, on the diagnosis and treatment of melanoma at Auckland District Health Board (DHB). METHOD: All patients attending the newly established Pigmented Lesion Clinic (PLC) between 1 March 2019 and 31 August 2019 were included in the study. They were compared against a retrospective cohort of patients seen for suspected or biopsy-proven melanomas during the same corresponding period in 2016. RESULTS: 251 new patients attended the PLC, compared to 148 new patients seen at Auckland DHB in 2016. There was a significant reduction in proportion of pigmented lesions requiring biopsy (35.2% vs 64.3%, p<0.001), with a benign-to-malignant ratio of 2.4:1. Fifty-three melanomas were treated through the PLC, with a significant reduction in mean waiting time from referral to first specialist assessment (22.6 vs 35.1 days, p=0.038), and from referral to wide local excision (50.6 vs 99.1 days, p<0.001). 86.5% of patients received full skin check, from which additional skin malignancies were detected in 1-per-5.3 patients. CONCLUSION: The novel PLC model has led to reduction in unnecessary excisional biopsies of benign pigmented lesions, while streamlining and improving timely access to specialist review and surgical treatment for patients with melanomas.

Aim

Method

Results

Conclusion

Author Information

Ken H-K Ip: Registrar, Dermatology Department, Auckland District Health Board, Auckland. Aravind Chandran: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland. Isaac Cranshaw: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Alex Ng: General Surgeon, General Surgery Department, Auckland District Health Board, Auckland. Ann Giles: Clinical Nurse Specialist, Dermatology Department, Auckland District Health Board, Auckland. Karen Agnew: Dermatologist, Dermatology Department, Auckland District Health Board, Auckland.

Acknowledgements

Correspondence

Karen Agnew, Dermatology Department, Auckland District Health Board, Greenlane Clinical Centre, 214 Greenlane West, Epsom, Auckland 1051, +64 9 307 4949 ext 26132

Correspondence Email

KAgnew@adhb.govt.nz

Competing Interests

Nil.

1. Jones WO, Harman CR, Ng AK, Shaw JH. Incidence of malignant melanoma in Auckland, New Zealand: highest rates in the world. World journal of surgery. 1999;23:732-5.

2. New Zealand Ministry of Health. New Cancer Registrations 2016. Available from: https://www.health.govt.nz/publication/new-cancer-registrations-2016 [accessed 18 November 2019]

3. Elwood JM, Kim SJ, Ip KH, et al. In situ and invasive melanoma in a high‐risk, New Zealand, population: A population‐based study. Australasian Journal of Dermatology. 2019;60:38-444.

4. Balch CM. Cutaneous melanoma: prognosis and treatment results worldwide. Seminars in surgical oncology. 1992;8:400-414

5. Pacifico MD, Pearl RA, Grover R. The UK Government two-week rule and its impact on melanoma prognosis: an evidence-based study. The Annals of The Royal College of Surgeons of England. 2007;89:609-15.

6. van der Geer S, Frunt M, Romero HL, et al. One‐stop‐shop treatment for basal cell carcinoma, part of a new disease management strategy. Journal of the European Academy of Dermatology and Venereology. 2012;26:1154-7.

7. Salam MA, Matai V, Salhab M, Hilger AW. The facial skin lesions “see and treat” clinic: a prospective study. European Archives of Oto-Rhino-Laryngology and Head & Neck. 2006;263:764-6.

8. Tran H, Chen K, Lim AC, et al. Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists. Australasian Journal of Dermatology. 2005;46:230-4.

9. Morrison A, O'Loughlin S, Powell FC. Suspected skin malignancy: a comparison of diagnoses of family practitioners and dermatologists in 493 patients. International journal of dermatology. 2001;40:104-7.

10. Vestergaard ME, Macaskill PH, Holt PE, Menzies SW. Dermoscopy compared with naked eye examination for the diagnosis of primary melanoma: a meta‐analysis of studies performed in a clinical setting. British Journal of Dermatology. 2008;159:669-76.

11. Sidhu S, Bodger O, Williams N, Roberts DL. The number of benign moles excised for each malignant melanoma: the number needed to treat. Clinical and Experimental Dermatology. 2012;37:6-9.

12. Lynch M, Tierney E, Roche L, et al. Melanoma diagnosis and management after the introduction of a pigmented lesion clinic in the Mid-West of Ireland. Irish Journal of Medical Science. 2017;186:671-5.

13. McGeoch G, Sycamore M, Shand B, Simcock J. A regional programme to improve skin cancer management. Journal of primary health care. 2015;7:339-44.

14. New Zealand Ministry of Health. Faster Cancer Treatment. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/national-cancer-programme/cancer-initiatives/faster-cancer-treatment [accessed 18 November 2019]

15. Dey P, Dixon JM, Bundred N, et al. Costs and benefits of a one stop clinic compared with a dedicated breast clinic: randomised controlled trial. BMJ. 2002;324:507-10.

16. Shah J. Assessment of activity and outcome from a one-stop clinic for men with suspected prostate cancer: Five years’ experience. Journal of Clinical Urology. 2016;9:5-10.

17. Aldridge RB, Naysmith L, Ooi ET, et al. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta dermato-venereologica. 2013;93:689-92.

18. Baade PD, Youl PH, English DR, et al. Clinical pathways to diagnose melanoma: a population-based study. Melanoma Research. 2007;17:243-9.

Contact diana@nzma.org.nz
for the PDF of this article

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