Performance of skin biopsies by general practitioners

Minor surgery in general practice in Ireland- a report of workload and safety

BACKGROUND

The provision of minor surgical services is an established part of the task profile of general practitioners (GPs) in many countries in Europe and elsewhere. This study aimed to collect data on the clinical process and outcomes for specified minor surgical procedures undertaken in Irish general practice by GPs experienced in minor surgery in order to document the scope and safety of minor surgery being undertaken.

METHODS

Over a six-month period, 24 GPs in 20 practices recorded data on a pre-determined list of procedures undertaken in adults (aged 18 and older); procedures for ingrown toenails were also recorded for those aged 12-18 years. Clinical data were rendered fully anonymous by the participating GPs, entered onto the Excel database template and returned to the project team monthly.

RESULTS

On average, each practice undertook 212 procedures in a six-month period. The four most frequent procedures include two relatively non-invasive procedures (cryosurgical ablation of skin lesions and aspiration and/or injection of joints) and two more invasive procedures (full thickness excision of skin lesion and shave, punch or incisional biopsy). Overall, 83.8% of relevant specimens were submitted for histology. Combining benign and malignant cases, there was an overall 87% clinical and histological concordance; 85% of malignancies were suspected clinically. A complication was recorded in 0.9% after 1 month.

CONCLUSIONS

Irish GPs with experience in minor surgery can provide a range of surgical services in the community safely.

Exérese de lipoma gigante na Clínica da Família: um relato de caso

A realização de procedimentos cirúrgicos na Unidade Básica de Saúde é preconizada e descrita na literatura. No entanto, tal prática vem sendo cada vez menos aplicada na atenção primária. Em um contexto de superlotações de hospitais terciários e consequente inoperação de cirurgias eletivas, é de extrema importância a realização desses procedimentos na Clínica da Família. Nesse trabalho, apresenta-se um caso de um paciente submetido à exérese de lipoma gigante incapacitante, na fossa poplítea esquerda, com 12 anos de evolução e com tentativa frustrada de resolução cirúrgica em um hospital terciário.

Comparing initial diagnostic excision biopsy of cutaneous malignant melanoma in primary versus secondary care: A study of Irish National data

BACKGROUND

The incidence of melanoma is rising worldwide. Current Irish guidelines from the National Cancer Control Programme state suspicious pigmented lesions should not be removed in primary care. There are conflicting guidelines and research advising who should remove possible melanomas.

OBJECTIVES

To determine whether initial diagnostic excision biopsy of cutaneous malignant melanoma in primary versus secondary care leads to poorer survival.

METHODS

Analysis of data comprising 7116 cases of cutaneous malignant melanoma from the National Cancer Registry Ireland between January 2002 and December 2011. Single predictor variables were examined by the chi-square or Mann-Whitney U test. The effects of single predictor variables on survival were examined by Cox proportionate hazards modelling and a multivariate Cox model of survival based on excision in a non-hospital setting versus hospital setting was derived with adjusted and unadjusted hazard ratios.

RESULTS

Over a 10-year period 8.5% of melanomas in Ireland were removed in a non-hospital setting. When comparing melanoma death between the hospital and non-hospital groups, the adjusted hazard ratio was 1.56 (95%CI: 1.08-2.26); (P = .02), indicating a non-inferior outcome for the melanoma cases initially treated in the non-hospital group, after adjustment for significant covariates.

CONCLUSION

This study suggests that initial excision biopsy carried out in general practice does not lead to a poorer outcome. [Box: see text].

Teaching elliptical excision skills to novice medical students: a randomized controlled study comparing low- and high-fidelity bench models

BACKGROUND

The search for alternative and effective forms of training simulation is needed due to ethical and medico-legal aspects involved in training surgical skills on living patients, human cadavers and living animals.

AIMS

To evaluate if the bench model fidelity interferes in the acquisition of elliptical excision skills by novice medical students.

MATERIALS AND METHODS

Forty novice medical students were randomly assigned to 5 practice conditions with instructor-directed elliptical excision skills' training (n = 8): didactic materials (control); organic bench model (low-fidelity); ethylene-vinyl acetate bench model (low-fidelity); chicken legs' skin bench model (high-fidelity); or pig foot skin bench model (high-fidelity). Pre- and post-tests were applied. Global rating scale, effect size, and self-perceived confidence based on Likert scale were used to evaluate all elliptical excision performances.

RESULTS

The analysis showed that after training, the students practicing on bench models had better performance based on Global rating scale (all P < 0.0000) and felt more confident to perform elliptical excision skills (all P < 0.0000) when compared to the control. There was no significant difference (all P > 0.05) between the groups that trained on bench models. The magnitude of the effect (basic cutaneous surgery skills' training) was considered large (>0.80) in all measurements.

CONCLUSION

The acquisition of elliptical excision skills after instructor-directed training on low-fidelity bench models was similar to the training on high-fidelity bench models; and there was a more substantial increase in elliptical excision performances of students that trained on all simulators compared to the learning on didactic materials.

Mortality and morbidity after initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care

BACKGROUND

Current UK melanoma guidelines do not support the initial diagnostic excision biopsy of pigmented lesions in primary care, although this is standard in other countries such as Australia. Previous research in Northeast Scotland found that initial diagnostic excision biopsies in primary care that prove to be melanoma were no more likely to be incomplete than those performed in secondary care, but data on longer-term outcomes were not available.

AIM

To determine whether initial diagnostic excision biopsy of cutaneous melanoma in primary versus secondary care leads to poorer survival and increased morbidity.

DESIGN AND SETTING

Analysis of a linked dataset comprising pathological data from melanoma cases diagnosed in Northeast Scotland between 1991 and 2007, the General Registry Office (Scotland) death registry, and an NHS Scotland episode of care database.

METHOD

Patient data from three sources were matched using the Community Health Index (CHI) number. Cox proportional hazards regression, with robust standard error estimates, was used to examine the hazard ratio (95% confidence interval) of key mortality and morbidity outcomes based on excision in primary versus secondary care. Analysis was conducted before and after adjustment for operator and patient-level factors, using a multilevel approach.

RESULTS

Patients receiving their initial diagnostic excision biopsy for melanoma in primary versus secondary care were no more likely to be dead, or to have died of metastatic malignant melanoma. Patients who had their initial diagnostic excision biopsy for melanoma in primary care had significantly fewer subsequent hospital admissions and spent fewer days in hospital.

CONCLUSION

These findings suggest that initial diagnostic excision biopsy of melanoma in primary care does not lead to poorer long-term outcomes.

Melanoma in primary care. The role of the general practitioner

BACKGROUND

The British Association of Dermatologists and the National Cancer Control Programme in Ireland discourage all GPs from biopsying any lesions suspicious of melanoma.

AIM

The aim of this study was to assess whether or not it is safe and practical for a general practitioner with extra training in dermatology and skin surgery to assess suspicious skin lesions and treat low risk melanomas.

METHOD

The outcome of 56 new melanomas (31 invasive, 7 in situ and 18 lentigo maligna) in 53 patients, managed by a GP with extra training in dermatology and skin surgery, over a 20 year period, was examined.

RESULTS

Forty-eight (86 %) of the melanomas had the initial biopsy carried out in primary care. The average time from presentation to the practice to the date of the biopsy was 8 days for the in situ and invasive melanomas and 17 days for the lentigo malignas. Twenty-eight (50 %) of the melanomas were considered low risk (in situ, invasive <1 mm deep or lentigo maligna) and were treated successfully in primary care according to the Australian and New Zealand guidelines, without any surgical complications.

CONCLUSION

GPs with extra training in skin cancer and skin surgery could assess most suspicious skin lesions with dermoscopy and if necessary, biopsy most of these lesions in primary care. This would lead to a quicker diagnosis, more rapid pathway to definitive treatment, lower cost and more convenience to the patient, especially for those living in rural areas.

Does patients' place of residence affect the type of physician performing primary excision of cutaneous melanoma in northern Scotland?

BACKGROUND

Rural residence may adversely affect cancer outcomes, perhaps because rural cancer patients are managed differently. Current UK guidelines recommend all patients with suspected melanoma be referred urgently for specialist excision biopsy; however, up to 20% of patients receive their biopsy in primary care. This project explored if rural dwellers with melanoma were more likely to have their primary biopsy in primary care.

METHODS

A clinical database of all primary cutaneous melanomas diagnosed in Northern Scotland between January 1991 and July 2007 was analyzed for patient demographics, clinical variables, and intermediate outcomes. Significant findings on univariate analysis were then included in a binary logistic regression model to adjust for confounders.

RESULTS

On univariate analysis patients living in rural areas were significantly more likely to have their melanomas excised in primary care compared with those living in the city (26.3% compared with 17.7%, P < .001). There were no significant differences between rural and urban dwellers in Breslow thickness or completeness of excision. Following adjustment for key confounders, those living in suburban areas and remote small towns were significantly more likely to be treated contrary to current UK melanoma guidelines compared to those in cities.

CONCLUSIONS

In Northern Scotland patients living in suburban areas and remote small towns are significantly more likely to have an initial melanoma excision in primary care, contrary to current UK guidelines. This geographical contrast signposts the way to further in-depth research into the interplay between place of residence and how the cancer journey is experienced.

Primary excision of cutaneous melanoma: does the location of excision matter

Melanoma is diagnosed more quickly if primarily excised in primary care, but current guidelines discourage this. The reports of all melanomas excised in north-east Scotland between 1991 and 2007 were analysed for adequacy of excision. Reports were analysed blinded as to source. Of primary biopsies performed in primary care, 72.5% were reported as completely excised, compared with 69.7% of those performed in secondary care (P<0.612). The difference remained non-significant following adjustment for important confounders.

Minor surgery activity in primary care

OBJECTIVE

The aim of this study was to describe the activity in our Outpatient Minor Surgery unit during its first five-year period.

DESIGN

Retrospective descriptive study.

METHODS

It was carried out in two centres of a Basic Health Area with a catchment area of 73,000 inhabitants.

PARTICIPANTS

Patients who underwent surgery from January 2002 to December 2007 were included in the research.

MAIN OUTCOME MEASURES

Information on the sociodemographic data of the patients, characteristics of the lesions, risk factors, treatment and its complications was gathered.

RESULTS

A total of 2317 surgical procedures was performed on 1520 patients. The mean was 46 years old and 52% were men. The concordance between clinical and anatomopathological diagnosis was 81%. There were complications in 5% of them. The main pathologies were: epidermoid cysts (22%), nevus (20%) and fibromas (18%). They were mainly located in the back (24%), superior extremities (14%) and head (11%). In 73% mepivicaine was used as anaesthetic. The most current techniques used were: incision (36%), curettage (33%) and fusiform excision (28%). Less than 1% had malignant lesions, 50% of which were not diagnosed clinically. The mean waiting time was 30 days. Ninety-two percent had the informed consent.

CONCLUSIONS

Minor surgery in primary care is feasible and has a good clinicopathological concordance and minimum complications, but some malignant lesions are overlooked in the diagnosis based exclusively on clinical criteria.

Recognition of skin malignancy by general practitioners: observational study using data from a population-based randomised controlled trial

Skin malignancy is an important cause of mortality in the United Kingdom and is rising in incidence every year. Most skin cancer presents in primary care, and an important determinant of outcome is initial recognition and management of the lesion. Here we present an observational study of interobserver agreement using data from a population-based randomised controlled trial of minor surgery. Trial participants comprised patients presenting in primary care and needing minor surgery in whom recruiting doctors felt to be able to offer treatment themselves or to be able to refer to a colleague in primary care. They are thus relatively unselected. The skin procedures undertaken in the randomised controlled trial generated 491 lesions with a traceable histology report: 36 lesions (7%) from 33 individuals were malignant or pre-malignant. Chance-corrected agreement (κ) between general practitioner (GP) diagnosis of malignancy and histology was 0.45 (0.36–0.54) for lesions and 0.41 (0.32–0.51) for individuals affected with malignancy. Sensitivity of GPs for the detection of malignant lesions was 66.7% (95% confidence interval (CI), 50.3–79.8) for lesions and 63.6% (95% CI, 46.7–77.8) for individuals affected with malignancy. The safety of patients is of paramount importance and it is unsafe to leave the diagnosis and treatment of potential skin malignancy in the hands of doctors who have limited training and experience. However, the capacity to undertake all of the minor surgical demand works demanded in hospitals does not exist. If the capacity to undertake it is present in primary care, then the increased costs associated with enhanced training for general medical practitioners (GPs) must be borne.

Excision of malignant melanomas in North Wales: effect of location and surgeon on time to diagnosis and quality of excision

BACKGROUND

The epidemiology of melanoma is changing and its current management is variable, with some lesions being removed in general practice. We aimed to determine the quality of excision and time to diagnosis relating to the excising surgeon and the place of excision.

METHOD

Analysis of data from the North Wales Melanoma Database.

RESULTS

In total, 578 cases were diagnosed 1993-2001. There was a gender difference with anatomical location, with 107 (65%) males with lesions on their trunk compared to 57 (35%) females. Median Breslow thickness was 1.10 mm (range 0.05-16.0 mm). Ninety-five (16%) lesions were removed in general practice, of which 49 (52%) were referred on to hospital. In total, 266 (61%) lesions were excised with 'adequate' margins and 170 (39%) excised with margins narrower than the guidelines. General practice excisions were from a younger group than hospital excisions. There were no differences in quality of excision between general practice and hospital excisions. Time to diagnosis was shorter overall for general practice excisions than hospital excisions (median 12 versus 41 days, P < 0.001).

CONCLUSION

These findings are of policy importance in that there is no evidence from this study that general practice excisions are managed poorly or have a worse prognosis.

Biopsy for malignant melanoma--are we following the guidelines?

INTRODUCTION

Guidelines for suspected malignant melanoma recommend a prompt, full-thickness excision biopsy allowing diagnosis and assessment of the Breslow thickness. Incisional biopsy is acceptable only for extensive facial lentigo maligna or acral melanoma. Punch, shave and other types of biopsies do not allow pathological staging and are, therefore, not recommended.

PATIENTS AND METHODS

A total of 100 referrals for histology-proven malignant melanoma were assessed retrospectively over a 1-year period (2005).

RESULTS

Of the 100 patients included in this study, 52 were male and 48 female. Ages ranged from 18-91 years, with a mean of 63 years. Origin of referrals was: dermatology, 63%; general practitioner (GP), 33%; and other sources in the remaining 4% of cases. Malignant melanoma was suspected in 84% and a benign lesion in remaining 16% of patients. However, only 56% of the patients were seen in our unit within 14 days of the referral as per the 2-week cancer rule. In these 100 patients, various types of biopsy were performed: 50 were referred without biopsy, 17 excision, 20 punch, 3 shave, 1 curettage, and 1 incisional biopsy. The type of biopsy was not recorded in the remaining 3 patients. Of the GP group, 48% were referred without biopsy, 12% had excision and 3% had incisional biopsies. The remaining 30% were punch, shave biopsies, and even curettage, inconsistent with current recommendations. Of the dermatology group, 54% were referred without biopsy, 21% underwent excision biopsy and 22% were punch biopsies. In total, 20 punch biopsies were performed, of which 7 were for lesions on the face ranging from 1.7-25 mm in size. The remaining punch biopsies were for lesions on the trunk or limbs (4-50 mm). Of the 20 punch biopsies performed, Breslow thickness was available in only 9 cases (45%). Sixteen of the punch biopsies were done when malignant melanoma was suspected and lesion otherwise was suitable for excisional biopsy. In the GP group, 3 shave biopsies and 1 curettage were performed, of which malignant melanoma was clinically suspected in one patient. The Breslow thickness was not obtained from any of the shave biopsies or curettage cases. Of the 17 excision biopsies performed, 3 were incompletely excised (2 by dermatology and 1 by GP).

CONCLUSIONS

A significant proportion of biopsies are inappropriate and inconsistent with the malignant melanoma guidelines. Punch biopsies are performed even when malignant melanoma is clinically suspected and excision biopsy is feasible. Only a small proportion of patients appear to be seen on an urgent basis within 14 days of referral. Such factors can lead to a delay in diagnosis, subsequent definitive treatment and adversely affect patient outcome. This study identifies a need to provide feedback and education to sources of malignant melanoma referrals.

The management of skin malignancy: to what extent should we rely on clinical diagnosis?

BACKGROUND

Cutaneous malignancy forms a major part of the dermatologist's workload. Clinical diagnosis is an important factor in facilitating the urgent excision of squamous cell carcinomas (SCC) and malignant melanomas.

OBJECTIVES

To identify the numbers and types of malignant skin tumours managed in an NHS teaching hospital and to assess the diagnostic accuracy.

METHODS

Data were collected on every histologically proven malignant skin lesion over a 6-month period.

RESULTS

One thousand one hundred and ninety-five malignant skin tumours were identified: 78% were basal cell carcinomas, 14% were SCC, 6% were malignant melanomas and the remaining 2% included Merkel cell tumours, malignant adnexal tumours and lentigo maligna. Eighty-one per cent of the tumours were managed by dermatologists. The correct clinical diagnosis had been made by the secondary care clinician in 84% of cases but an incorrect clinical diagnosis was given in 32% of SCC. Of the 1195 tumours, 916 (77%) had a primary excision and 92% (843 of 916) of these were completely excised.

CONCLUSIONS

The majority of skin malignancies (968 of 1195, 81%) were managed by dermatologists. Where primary excision was attempted, this was complete in 91% (767 of 916) of cases. The correct clinical diagnosis was made in 84% of all tumours, but 32% of SCC were not correctly diagnosed prior to surgery.

A retrospective biopsy study of the clinical diagnostic accuracy of common skin diseases by different specialties compared with dermatology

BACKGROUND

With the recent trend for nondermatologists to treat dermatologic disorders, this retrospective biopsy study reviews the accuracy of the clinical diagnosis of physicians of different specialties performing surgical dermatologic procedures.

OBJECTIVE

We assessed the diagnostic abilities of nondermatologist physicians who performed various types of skin biopsies and compared them with those of dermatologists.

METHODS

The clinical diagnoses of family physicians, plastic, general, and orthopedic surgeons, and internists and pediatricians versus dermatologists were correlated with the histopathologic diagnoses. In total, 4451 cases were analyzed.

RESULTS

Dermatologists diagnosed twice the number of neoplastic and cystic skin lesions correctly (75%) than nondermatologists (40%). The clinical diagnosis rendered by family practitioners matched the histopathologic diagnosis in only 26% of neoplastic and cystic skin lesions. Plastic surgeons, who performed the largest number of cutaneous surgical procedures among the nondermatologists, did better in the recognition of skin tumors than family physicians, but still had a diagnostic accuracy rate of only 45%. Inflammatory skin diseases were correctly diagnosed in 71% of the cases by dermatologists but in only 34% of the cases by nondermatologists.

LIMITATIONS

A limitation of this retrospective, unblinded study is the use of the clinical data from the pathology requisition form as a surrogate for clinical diagnostic accuracy.

CONCLUSIONS

The overall accuracy of the clinical diagnosis depends heavily on the clinicopathologic correlation. Without sufficient clinical data, the histopathologic diagnosis will be limited or restricted. This review concludes that without basic dermatology knowledge, clinicopathologic correlation is compromised.

Ten Years of Skin Malignancies in a Single General Practice

BACKGROUND

Generalists within the UK have for many years been performing minor surgical procedures. Little has been published concerning this activity.

OBJECTIVES

To determine the management of skin malignancy in a UK general practice in order to allow comparison of activity with other practices and disciplines and to identify areas for research.

METHODS

Retrospective cohort study in an urban 4-partner general practice of 10,000 patients. Total ascertainment of all diagnosed skin malignancies over 10 years achieved by undertaking computerised searches.

RESULTS

136 skin malignancies were identified in 101 patients. The recurrence rates for basal cell carcinomas managed in primary care were comparable to rates published for secondary care. A quarter of patients developed a metachronous skin malignancy or a recurrence.

CONCLUSION

Almost half of all skin malignancies were wholly managed within primary care. There appeared to be no consistent pattern of management. There is a need for research and consensus on optimal care.

[Pre-malignant and malignant lesions in minor surgery at a health centre. Appearances can't be trusted]

OBJECTIVE

To describe the characteristics of the malignant and pre-malignant lesions found in the minor surgical interventions performed at a health centre.

DESIGN

Retrospective, descriptive study.

PARTICIPANTS

682 lesions: all the lesions extirpated and referred to pathology except for epidermal and trichilemmal cysts, lipomas, molluscum, common warts, and nails.

SETTING

Rochapea Health Centre, Pamplona.Main measurements. We analysed the anatomical-pathological results and the distribution by sex, age-group, location, technique and edges affected in 27 dysplasias and 11 malignant lesions.

RESULTS

We found that malignant and pre-malignant lesions were more common in women, aged 15 to 44 for dysplasias and 45-64 for malignant lesions. The most common location was on the back; the most frequent technique, fusiform excision. This technique had the highest percentage of edges without lesion in dysplasias. The lesions whose edges were affected corresponded to punch and circular excision samples. None of the malignant lesions had their edges affected.

CONCLUSIONS

Most malignant lesions are not suspected. They appear in samples referred with a diagnosis of benign. Employment of techniques such as fusiform excision in lesions which are potentially malign, even though in principle they seem benign, enables them to be extirpated with free edges.

The potential impact on melanoma mortality of reducing rates of suboptimal excision margins

We estimated the potential benefit of reducing rates of inadequate excision margins in the treatment of localized invasive melanoma. A computer-simulated Markov decision analytic model was created to follow until death a hypothetical cohort of 55 y old Caucasians, newly diagnosed in a community setting with localized invasive melanoma. We considered two scenarios: usual care, and a hypothetical intervention. Markov states included well without local recurrence, local recurrence, cured, and dead. Published population-based data were used for rates of optimal excision margins, local recurrence, and mortality. Two outcome measures were employed: melanoma-related mortality and life expectancy. Major assumptions included: local recurrence occurs within 10 y of diagnosis, and patients revert to general population mortality rates 10 y following melanoma excision or subsequent local recurrence. For usual care, the model estimated 8.17% melanoma-related mortality. Modeling intervention with 100% optimal excision margins reduced this rate to 6.15%, a 25% relative reduction in mortality. This increased average life expectancy by 0.437 y, which equates to approximately 11 additional years in the 4% who would not experience a local recurrence due to improved excision margins. Increasing the percentage of optimal excision margins to 80% would still yield substantial improvement, with 6.83% melanoma-related mortality, saving 0.29 life-years compared with baseline. Results were insensitive to moderate changes in the parameter values. Suboptimal excision margins may account for approximately one-fourth of all melanoma-related mortality for localized invasive melanoma. If intervention can achieve even modest adherence to optimal excision margins, it might substantially reduce mortality.

[Minor surgery in primary care: is continuing education within the team a valid strategy for improving quality?]

OBJECTIVE

To evaluate the impact of continuing education within the team (FCI, in Spanish) on the quality of minor surgery.

DESIGN

Study of level of quality. SETTING. Primary care.

PARTICIPANTS

First evaluation: all the lesions referred for biopsy during 1998 (62 samples). Second evaluation: those referred in 1999-2000 (150).

MAIN MEASUREMENTS

Four explicit criteria regulating procedure and result were designed: C1, sufficient information; C2, correct referral; C3, correct extirpation of lesion; C4, clinical-pathological concordance. Request forms and anatomical-pathological reports were assessed. Evaluation was before and after corrective measures (FCI and organisational changes designed to support FCI). The Kappa index of inter-observer concordance, the Compliance Index and Fisher's Z index were analysed.

RESULTS

62 lesions were included in the first evaluation, with high reliability for C1 and C4, good for C2 and moderate for C3. 150 lesions were included in the second evaluation. The compliance indices showed statistically significant increases from the first to the second evaluation for C1 (38.09% and 50.66%, relative improvement of 19%) and C4 (68.85% and 85.2%, relative improvement of 53%). C2 showed an improvement, but without statistical significance (87.30% and 92.66%). The compliance index for C3 dropped (94.73% and 87.50%). 5.33% of cases in the second evaluation (8 biopsies) were malignant or pre-malignant lesions, compared with 20.96% in the first (P<.05). 100% of these latter showed free resection limits. 77.99% of lesions studied through a biopsy in the second evaluation were nevus, seborrhoeic keratosis or dermatofibroma.

CONCLUSIONS

FCI is a valid strategy for improving the quality of programmes of minor surgery in primary care. There was significant improvement in the identification of malignant and pre-malignant pathology, in correct referral and in the clinical-pathological concordance of the lesions.

Inter-observer variation in the histopathological diagnosis of clinically suspicious pigmented skin lesions

When a biopsy is taken of a suspicious pigmented skin lesion, histological examination is expected to establish the definitive diagnosis. This study evaluated the inter-observer variation of 20 pathologists in the histological diagnosis of a randomly selected set of suspicious pigmented skin lesions (PSLs), by comparing their diagnoses to a reference diagnosis. Overall sensitivity for melanoma was 87%, ranging from 55% to 100% between the observers. Sensitivity was significantly lower for thin (Breslow thickness <1 mm) than for thick melanomas (83% versus 97%, p=0.005). Overall melanoma specificity was 94%, ranging from 83% to 100% between observers. Dysplastic naevus was the most important source of false-positive diagnoses, mainly in situ melanomas. Positive and negative predictive values in the given test set were 75% and 97%, respectively. In the case of melanoma, there was quite some variation in measured Breslow thickness. This would have led to a different therapeutic approach in 12% of the readings. Some of the variation seemed to be due to a different interpretation of the presence of a co-existent naevus. In 9% (3/35) of the readings, participants did not agree on the presence of ulceration. These results reflect a tendency to overdiagnose mainly thin melanomas in general histopathological practice. They also demonstrate variation in the assessment of major prognostic factors of melanoma.

[Clinicopathological correlation in 370 cases of skin minor surgery carried out by family physicians]

OBJECTIVE

To analyse the concordance between presurgical diagnosis and anatomical pathology diagnosis in 370 cutaneous lesions in primary care centres.

DESIGN

Descriptive study.Setting. Primary care centres and hospital pathology service, Medina del Campo.

MEASUREMENTS AND MAIN RESULTS

The prior diagnosis was compared with the anatomical pathology for simple agreement. There were 370 lesions. Complete date were obtained for 345 lesions of 298 patients (156 male and 142 female, aged between 6 and 98). Most problems diagnosed were nevocellular nevi (99 cases), fibroepithelial papiloma (72 cases), epidermoid cyst and viral wart (44). There was 63.1% global agreement between the laboratory report and doctor's diagnosis. Concordance and misdiagnosis were described in each type of lesion, mostly in skin cancer.

CONCLUSIONS

Performing minor surgery in primary care is feasible and effective. There is a high concordance between clinical diagnosis and anatomical pathology diagnosis.

Changing trends in non-melanoma skin cancer in South Wales, 1988-98

BACKGROUND

In 1988 our department carried out a population-based epidemiological study of non-melanoma skin cancer (NMSC) incidence, over a 6-month period, in West Glamorgan, South Wales. Objectives To reassess the incidence of NMSC in this defined population over a similar 6-month period 10 years after the initial study.

METHODS

All cases of basal cell carcinoma and squamous cell carcinoma diagnosed in West Glamorgan are recorded by the local skin cancer registry. All cases for the relevant 6-month period were analysed.

RESULTS

Using these figures, we have identified a significant rise in the crude incidence of NMSC from 173.5 10 years ago to 265.4 per 100,000 population per annum. We also applied the world standard population for age to our crude figures, demonstrating a combined male and female world population-corrected rate of 129.9 per 100,000 population.

CONCLUSIONS

In our population the crude incidence of NMSC has risen significantly over 10 years. Additionally, the combined male and female world population-corrected rate appears to be the highest published standardized incidence of NMSC to date from any European country.

[Minor surgery in primary care: consumer satisfaction]

OBJECTIVE

To find the satisfaction of patients undergoing minor surgery at health centres and describe the processes.

DESIGN

Retrospective study of population seeking the service.

SETTING

Health district.

PATIENTS

160 people who had minor surgery during a year.

MEASUREMENTS AND MAIN RESULTS

Descriptive variables of everyone who had minor surgery were analysed: age, sex, type of intervention, pre-surgical diagnosis, anatomical-pathological diagnosis and informed consent. Over three weeks the patients were interviewed by phone with use of a satisfaction questionnaire. 160 interventions took place, 80% of which were then studied histologically, with an 83.16% concordance index. 65% of patients were interviewed. 15% had no telephone, 20% were not found, 95.56% considered they were well attended and 3.17% badly attended. 92.06% would choose the health centre again for procedures of a similar nature. 89.9% thought that the explanations they had received were sufficient. 4.4% thought that the room's hygiene was poor.

CONCLUSIONS

Minor surgery in primary care was favourably received by users. Activity at our centre had good anatomical-pathological concordance.

Melanoma excision by general practitioners in north-east Thames region, England

A retrospective study of pathology reports of melanomas excised by general practitioners (GPs) was undertaken in the course of a population-based study of melanoma, with a telephone survey of the current practice of those GPs who had excised melanomas. The objectives of this study were to identify all cases of cutaneous melanoma excised by GPs in the North-East Thames Region between 1989 and 1993, and to review the management of those patients. The main outcome measures of the study were: (i) the patterns of distribution of GP excisions within the region; (ii) the histological subtypes of melanomas excised, the accuracy of the pre-excision clinical diagnosis and the adequacy of treatment of the GP-treated tumours compared with the control group; and (iii) the reported current practice in the management of pigmented skin lesions by the GPs who had excised melanomas. Eight hundred and nineteen melanomas were excised in the region during the study period, of which 59 were excised by GPs. The Breslow thickness of tumours was similar in both GP-excised and non-GP-excised groups. Tumours were more likely to be amelanotic in the GP-excised group (P < 0.001). Incomplete excision was significantly more likely in the GP group (P < 0.001). The GPs made a confident clinical diagnosis of melanoma in only 17% of patients prior to surgery. The reported referral rate to specialists by this subset of GPs of patients with pigmented lesions was low, and at interview half of the GPs reported that they felt confident enough to manage patients with suspected skin cancers on their own. The majority of the GPs did not routinely obtain histological examination of skin lesions they believed to be benign. In conclusion, there are problems with the accuracy of clinical diagnosis and inadequacy of excision of melanomas removed in primary care. In the majority of cases, however, patients were subsequently appropriately treated by referral to specialist units. There was an under-usage of pathological examination of samples by the GPs interviewed.

Evaluation of minor surgery courses for general practitioners

This paper describes the evaluation of a two-day minor surgery training course for general practitioners and vocational trainees. The course was developed by a team from a wide range of specialties. A pilot run of six of these courses was held in various locations in the United Kingdom during 1994, organized by the Royal College of General Practitioners and supported by the Department of Health. The courses were attended by 144 participants in total: 52 general practitioners and 92 vocational trainees. The evaluation addressed (a) the process of training which resulted in substantial changes being made to the original design and content of the courses; and (b) the outcome of the training in terms of knowledge, confidence and competence. A central feature of the course was the use of sophisticated simulated tissue. Participant feedback indicated that although the simulated tissue was not considered to be very realistic it substantially increased levels of confidence and competence to carry out minor surgery. Knowledge on various aspects of minor surgery increased significantly. The feedback from the evaluation was forwarded to a minor surgery working party at the Department of Health whose remit was to prepare guidelines for teaching, authorising and carrying out minor surgery in general practice.

Skin cancer diagnosis in a primary care setting

BACKGROUND

Primary care providers are in a good position to detect sk in cancers early, but their current involvement in diagnosis and referral of patients with skin cancer is unknown. Some managed care settings utilize a primary care case manager approach to health care.

OBJECTIVE

The purpose of this study was to assess the incidence and demographic associations of skin cancer in a managed care population served by primary care providers.

METHODS

this study analyzed 1215 skin biopsy specimens obtained by family physicians, internists, and supervised certified physician assistants within an eastern Washington health maintenance organization and the 69 biopsy specimens obtained by referral specialists and confirmed by pathologic consultation.

RESULTS

Internists, family physicians, and their physician assistants performed 94.7% of the biopsies on 87% of all malignancies. Dermatologists and surgeons performed the rest. Primary care providers and dermatologists detected malignant melanomas at a rate comparable to a similar study from British Columbia but lower than other previous investigations.

CONCLUSION

Melanomas were diagnosed in this managed care system at a rate comparable to a similar system in Canada. Lower rates for other skin cancers are probably because of methodologic differences from other studies, but variation in histologic diagnoses between pathologists and differences in skin cancer detection cannot be excluded.

Prospective audit of mucosal biopsy specimens of the gastrointestinal tract

AIMS

To determine why mucosal biopsy specimens of the gastrointestinal tract were taken and whether they were justified on clinical or pathological grounds.

METHODS

A prospective audit of 190 consecutive biopsy specimens received in a university hospital histology department over six weeks.

RESULTS

The 31 separate presenting symptoms included diarrhoea (34%), abdominal pain (16%) and rectal bleeding (15%). In 41% (78/190) the histology was normal, 28% (53/190) showed inflammatory changes and 11% 21/190) carcinoma. A clear justification for the procedure was identified in over 90% (171/190) of patients. In 36% (68/190) there was a change in patient management on receipt of biopsy reports and further investigations were ordered in 29% (55/190). The mean time taken to report biopsy specimens was 4.7 working days and there was no difference between the reporting time of a pathologist compared with a consultant or a trainee.

CONCLUSIONS

There is no evidence that mucosal biopsy specimens are taken unnecessarily.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. I. Work-load and referral patterns

From 1987 to 1989 a campaign to promote the early detection of cutaneous malignant melanoma was conducted in the areas of seven health authorities in England and Scotland (total population 3.6 million). Data were collected on 17,155 patients attending pigmented lesion clinics (PLCs) in each study area during the campaign. After a dramatic rise in PLC referral rates in the first month of the campaign the average monthly referral rate among the target population in the study period settled to an average of 13 per 10(5), a twofold increase compared with the pre-campaign period. Over 85% of patients at all PLCs were seen within 4 weeks of referral from their general practitioners. The melanoma to non-melanoma detection ratio was (1:33). The organization of future early detection initiatives needs careful review and planning, in order to improve their effectiveness in all sections of the population, and to enable health services to cope with the increased work-load.

Prevention, early detection and team management of skin cancer in primary care: contribution to The health of the nation objectives

The incidence of all skin cancers is increasing. If The health of the nation targets are to be addressed, incidence figures need to be more accurate. Solar damage is the major causal factor in all skin cancers. Certain individual risk factors also play an important part, especially in the development of malignant melanoma. Prevention and early detection are crucial in reducing morbidity and mortality from skin cancer. This paper considers the role of primary care skin screening clinics and cutaneous surgery facilities in the early detection and management of skin cancer. It also illustrates the value of a team approach in primary care in the prevention and early detection of skin cancer and in the more accurate recording of incidence rates.

Quality of minor surgery by general practitioners in 1990 and 1991

BACKGROUND

The 1990 contract for general practitioners encouraged them to undertake minor surgical procedures in their practices.

AIM

A study was undertaken to determine whether the subsequent expansion of general practitioner minor surgery activity was accompanied by changes in quality of care.

METHOD

Data were analysed relating to minor operations conducted in 22 practices during April-June 1990 and April-June 1991.

RESULTS

The volume of general practitioner minor surgery increased by 41% between the two study periods. Waiting time, accuracy of diagnosis, use of histology, adequacy of excision, complications and the need for corrective treatment in hospital did not change significantly between the two periods.

CONCLUSION

The findings do not support suggestions that the expansion of general practitioner minor surgery activity following the 1990 contract has been associated with an erosion of quality of care.

Profile of the malignant melanoma excised in general practice

An analysis of 27 malignant melanomas diagnosed in a Dutch laboratory specializing in the provision of a cytology and pathology service to general practitioners is reported. The median age of the patients was 39 years, and was lower in women (30 years) than in men (54 years). In the national data the mean age was 52 years for both sexes. There were twice as many women as men. There were no tumours from the head and neck region. The ratio of tumours on the limbs to those on the trunk was 3:2. The melanomas were very small (74% with a diameter of < or = 6.0 mm), and they were also very thin (74% with a Breslow thickness < or = 1.0 mm), compared with the national data in which 62% were < or = 1.0 mm. Not surprisingly, the estimated mean 5-year survival was favourable (95% for women and 76% for men). After a period of follow-up ranging from 2 to 32 months, none of the patients had any evidence of residual disease. This study demonstrates that in skin biopsies performed by general practitioners melanomas are mainly detected by chance, and have a very good prognosis.

Use of histopathology services by general practitioners: recent changes in referral practice

AIMS

To determine the nature and magnitude of the histopathological workload generated by specimens received from general practitioners and to assess the trends in referral practice.

METHODS

All material submitted by general practitioners to the Leicester district histopathology service from 1989 to January 1993 was identified from departmental records. All GP referrals from October to December 1992 were also analysed. Total numbers of referrals from all sources were used for comparison. Specimens were also analysed according to diagnostic categories.

RESULTS

There has been a progressive rise, both in the absolute number and the proportion of specimens relative to other surgical specimens submitted by GPs. Most are skin biopsy specimens. There were clear changes over the study period in the relative proportion of different types of lesions received, with a substantial increase in samples of benign naevi and papillomas. There was some evidence of a corresponding decrease in the number of these lesions submitted by hospital practitioners. The number of malignant skin tumours from GPs was small and the proportion had not increased over the study period.

CONCLUSIONS

Histopathological workload generated by GPs is increasing but it still represents a small proportion of the total. The major increase is in benign skin lesions.

Minor surgery by general practitioners under the 1990 contract: effects on hospital workload

OBJECTIVE

To determine the extent to which minor surgery undertaken by general practitioners after the introduction of the 1990 contract substituted for hospital outpatient workload.

DESIGN

Before and after observational study.

SETTING

Four English family health services authorities.

SUBJECTS

Patients in 22 practice populations who were operated on by their general practitioner or referred to hospital for minor surgery during April to June 1990 or April to June 1991.

MAIN OUTCOME MEASURES

Numbers of minor surgical procedures undertaken in general practice and in hospital, numbers of referrals to hospitals for conditions treatable by a minor surgical procedure, and the mix of diagnoses and procedures undertaken in each setting.

RESULTS

General practitioners claimed reimbursement for 600 minor surgical procedures during April to June 1990 and for 847 during April to June 1991, an increase of 41%. Referrals to hospital for comparable conditions showed no compensatory decrease (385 during April to June 1990 and 388 during April to June 1991, 95% confidence interval for change in referrals -51 to 57), and the number of hospital procedures resulting from those referrals also remained constant (187 in the first period, 189 in the second, 95% confidence interval for change in procedures -36 to 40). The mix of procedures did not change significantly from one study period to the next in either setting.

CONCLUSIONS

Many or all of the additional patients receiving minor surgery under the terms of the 1990 contract may not have previously been referred to hospital. General practitioners seem not to have systematically shifted towards treating the more trivial cases. The overall increase in minor surgical activity may reflect an improvement in accessibility of care or changes in patients' perceptions and attitudes.

Cryptosporidiosis in infancy and childhood mortality in Guinea Bissau, west Africa

OBJECTIVE

To investigate the epidemiology of and mortality from cryptosporidiosis in young children in Guinea Bissau, West Africa.

DESIGN

Three year community study of an open cohort followed up weekly.

SETTING

301 randomly selected houses in a semi-urban area in the capital, Bissau.

SUBJECTS

1315 children aged less than 4 years.

MAIN OUTCOME MEASURES

Cryptosporidium infection detected by examination of stools during episode of diarrhoea and death of a child.

RESULTS

Cryptosporidium spp were found in 239 (7.4%) out of 3215 episodes of diarrhoea. The parasite was most common in younger children (median age 12 months) and at the beginning of the rainy seasons. The prevalence of cryptosporidiosis was 15% (77/513) in cases of persistent diarrhoea compared with 6.1% (148/2428) in diarrhoea lasting less than two weeks (p < 0.0001). Cryptosporidiosis was associated with excess mortality in children who had the infection in infancy, and this excess mortality persisted into the second year of life (relative mortality 2.9 (95% confidence interval 1.7 to 4.9)). The excess mortality could not be explained by malnutrition, or by socioeconomic factors, hygienic conditions, or breast feeding.

CONCLUSIONS

Cryptosporidiosis is an important cause of death in otherwise healthy children in developing countries.

Skin biopsies of pigmented skin lesions performed by general practitioners and hospital specialists

The performance of skin biopsies by general practitioners has been examined in several recent studies. The aim of this study was to examine the difference between skin biopsies of pigmented skin lesions taken by general practitioners and those taken by hospital specialists. Reviewing all histopathology records at one hospital over a five year period revealed that there were 1000 patients who had had skin biopsies. General practitioners had carried out skin biopsies for 55% of these patients. Hospital specialists excised significantly more lesions that had increased in size (P < 0.001) or changed in colour (P < 0.001). General practitioners excised more lesions that had bled (P < 0.001). Hospital specialists excised more of the 15 melanomas diagnosed (80%) (P < 0.05), and general practitioners excised more squamous papillomas (P < 0.01). Forty per cent of melanomas excised were not suspected by the clinician. General practitioners were able to detect the majority of suspicious lesions, but because of the uncertainty of clinical diagnosis, all specimen's should be submitted for histopathological diagnosis. It is important that future general practitioners are trained in both the diagnostic and technical aspects of skin biopsy if they intend to perform this minor operation.

Developing a research and development strategy for primary care

General practice research has been a minority activity and underfunded in the past. The creation of the purchaser and provider split, the introduction of medical audit, and the new research and development strategy for the NHS provide an opportunity to focus research on the health needs of the population. FHSAs, with the regional health authority, should develop a local strategy for research and development and appoint a lead officer, who may be the medical adviser. When negotiating contracts FHSAs need to back up their arguments with research evidence. NHS development research should cover quality, distribution, accessibility, outcome, and effectiveness. FHSAs should play a part in disseminating knowledge in the interests of achieving an effective and high quality service. GPs should be encouraged to participate in research by relaxing the regulations of compulsory hours of patient service and by creating a practice development allowance.

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91

OBJECTIVE

To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this.

DESIGN

A retrospective case-control study.

SETTING

South east Scotland.

SUBJECTS

All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91.

OUTCOME MEASURES

Demographic details of patients; Breslow thickness, clearance of excision.

RESULTS

42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis.

CONCLUSIONS

General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.