Dr Stephen Hayes Associate Specialist in Dermatology University Hospital Southampton

Transcription

1 South East Dermatology Transformation and Sustainability Network Guildford, 19 th April 2018 Dermoscopy as an effective skin lesion triage tool in GP surgeries Dr Stephen Hayes Associate Specialist in Dermatology University Hospital Southampton

2 Dr Stephen Hayes declaration of interests Former GP, GPwSI Associate Specialist University Hospital Southampton Dermoscopy educator for reward Life Member Primary Care Dermatology Society Blogs about dermoscopy UK Board Member, International Dermoscopy Society

3 GP suspected skin cancer referrals up 41% in 5 years, mainly due to NICE guidance The Independent 1 st September 2014

4 A thought from Rudyard Kipling. I keep six honest serving men, (They taught me all I knew) Their names are What, and Why, and When, And How and Where and Who.

5 What? The skin cancer epidemic, that s what. And the shortage of NHS dermatologists And the variable lesion recognition skills of most GPs

6 South west skin cancer hub-a great source of data

7 A tale of two cancers... Change in UK mortality Cervical cancer deaths 957 Melanoma deaths 2,067

8 Melanoma now 5 th most common UK cancer excluding BCC+ SCC

9 Why?

10

11 Ulcerated nodule on scalp-diagnosis was easy. Male, 80 presented with blue/grey ulcerated nodular melanoma. Dead from metastatic melanoma 6 weeks later.

12 Why? Rising public concern about skin cancer Plus GP conscious incompetence at skin lesion diagnosis Plus mandatory urgent cancer pathway Minus Enough NHS dermatologists Equals = stress on secondary care dermatology services We have sound international peer-reviewed evidence that dermoscopy by suitably trained GPs can make a useful difference to this problem

13 How? -by training GPs to be consistently good enough at evaluating skin lesions and grading them accurately, at the first consultation. In 2018, this inevitably involves dermoscopy skills. As little as one day of dermoscopy training can transform a GP s ability to recognise skin lesions.

14 Dermoscopy-a scope like any other! Illuminates Magnifies Breaks down refraction Reveals unseen additional data

15 A range of dermoscopes Heine Delta 20 Plus DermLite II Pro HR DermLite DL3 Opticlar Dscope

16 Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol Apr 20;24(12): Argenziano G 1, Puig S, Zalaudek I. et al 73 GPs in Barcelona and Naples were given a 1-day training course in skin cancer detection and dermoscopic evaluation, and were randomly assigned to the dermoscopy evaluation arm or naked-eye evaluation arm. During a 16-month period, 73 physicians evaluated 2,522 patients with skin lesions who attended their clinics and scored individual lesions as benign or suggestive of skin cancer. All patients were re-evaluated by expert dermatologists at clinics for pigmented lesions. Referral accuracy of both groups was calculated by their scores, which were compared to those tabulated for dermatologists. RESULTS: Significant differences were found in terms of sensitivity and negative predictive value. Histopathologic examination of equivocal lesions revealed 23 malignant skin tumors missed by GPs performing naked-eye observation and only 6 by GPs using dermoscopy (P =.002) The use of dermoscopy improves the ability of GPs to triage lesions suggestive of skin cancer without increasing the number of unnecessary expert consultations.

17 Dermoscopy, a useful tool for general practitioners in melanoma screening: a nationwide survey British Journal of Dermatology February 2016, Chappuis, Duru, Marchal, Girier, Dalle, Thomas A study to evaluate dermoscopy use by French GPs 4,057 French GPs were surveyed by questionnaire, a tenth responded Only 8% had access to a dermoscope Of this 8%, only 47% had received any training in dermoscopy. Most of them had received very short and recent training

18 Conclusions of French GP dermoscopy use study Our study demonstrates positive opinions regarding dermoscopy, despite a minority of French GPs using this technique in the areas surveyed. The need for formal training appears to be the main limitation to wider use. Appropriate and specifically designed training programmes should be offered.

19 International evidence for dermoscopy is strong

20 Australian evidence summary

21 While there are fewer studies on dermoscopy in primary care (general practice), all five that were undertaken in this context show a consistently improved sensitivity for the diagnosis of melanoma or the identification of suspicious lesions requiring biopsy. [7][18][19][21][22].. based on other evidence where lack of training can lead to a reduction of diagnostic accuracy [23] some formal training in dermoscopy is required to achieve improvement in diagnostic accuracy.

22 Lesions dermoscopy helps diagnose Benign naevi Seborrhoiec warts Haemangiomas Dermatofibromas Basal cell cancers Bowen s disease Melanomas and dysplastic naevi The main role of GP dermoscopy is to screen these benign lesions out

23 Dermoscopy is an invaluable screening tool Nodular melanoma?

24 Dermoscopy is invaluable Nodular melanoma? No, it s a harmless haemangioma.

25 Worries about this big black mole?

26 Dermoscopy abundant yellow and brown clodsa typical feature of harmless seborrhoeic keratosis

27 Scary mole?

28 Dark but harmless naevus

29 Benign or malignant-you MUST wager!

30 How much will you wager now?

31 How hard is it to learn to use a dermoscope?

32 Learning new skills is possible! There is help.

33 Free on line dermoscopy education resources Primary Care Dermatology Society web site International Dermoscopy Society (IDS) IDS Facebook DERMATOSCOPY page (15,000 members world wide, new cases for discussion posted daily) Eric Erhsam s blog Stephen Hayes s blog (cases plus many links to other free on line resources) Ian McColl s Australian site YouTube-many excellent dermoscopy videos by IDS board members

34 Dermoscopy courses which cost money (web addresses and details are omitted in the interest of probity and to avoid bias, all can be Googled) PCDS (Dermoscopy for Beginners and Advanced Dermoscopy) University of Cardiff (on line course) University of Hertfordshire Jonathan Bowling (dermoscopy UK) South Coast Dermoscopy St John s Institute (Advanced dermoscopy course) This list may not be complete

35 Future developments in skin cancer detection? Artificial intelligence and computer diagnosis? Teledermoscopy? Smartphone apps? Sniffer dogs? Hmm, very interesting, but What about training and equipping one GP in every surgery with well proven, affordable technology that has been around for 2 decades, and which we already know works?

36 A proposal Recognise the magnitude of the skin cancer problem Recognise that most GPs are inadequately skilled to confidently and safely do the job that is required of them re skin lesion triage Recognise that we have too few dermatologists by international standards Form partnerships between stakeholder groups (BAD, RCGP, NHSE, purchasers, educators and clinicians). Design and implement realistic and affordable plans to improve diagnostic skills and performance, in order to pick up melanomas earlier and reduce avoidable referrals to secondary care. This will involve dermoscopy training.

37 Thank you for inviting me and listening Dr Stephen Hayes Dermoscopy educator