Non-melanoma skin cancer and the ‘new National Health Service’: implications for U.K. dermatology?

Most dermatology units in the U.K. are becoming increasingly stretched for resources. This is due to a combination of factors including the demands of an increasingly educated and informed public 1 and raised patient expectations for a comprehensive National Health Service (NHS). In addition, general practitioners (GPs), who often have difficulty with dermatological diagnoses, 2 refer many benign lesions to dermatology clinics, believing them to be possible skin cancers. This, coupled with an increasing incidence of skin cancer 3–5 and the workload consequent upon an ageing population, 6 adds to the burden on dermatology departments. Multiple initiatives such as the Patient’s Charter and the Department of Health Performance and Outcomes Data are expected to bring about internal quality improvements within Trusts. 7 The recent Government White Paper 8 on the NHS states that by the year 2000, patients with any suspected cancer are expected to be seen by a specialist within 2 weeks. If this aim were extended to cover non‐melanoma skin cancer (NMSC), then most dermatology departments in the U.K. would fail to meet this target. NMSC is by far the most frequent cancer in the U.K., but mortality remains low even though these tumours have substantial cosmetic and service implications. 9 Worldwide, the incidence of NMSC varies widely with, for example, a nearly 50‐fold difference in the incidence of basal cell carcinoma (BCC) and 100‐fold difference in squamous cell carcinoma (SCC) noted between the white populations in Northern Europe and Australia. 10 While cumulative sun exposure is likely to be the most important explanatory factor for such differences, 10 genetic predisposition is also important. For example, the incidence of NMSC is low in Finland, accounting for 3·5% of all new cancer cases, whereas in Northern Ireland 11 it accounts for over 26% of all cancers. BCC is the most common NMSC, comprising 80% of all cases. 10, 11 While effective treatments exist for BCC, 12 they can be time consuming and costly. 9, 13 Such patients have a significant risk of developing new primary lesions 14–16 and their review places further demands on dermatology departments. 17 However, looking past the workload created by BCCs, metastases are rare, and mortality only occurs in around 0·03% of cases, 18 with most occurring in rare giant BCCs. 18, 19 Two recent articles in this journal 20, 21 (one published on page 446 of this issue) have examined the increase in size of BCCs during the period that patients remain on NHS waiting lists. While one of these studies showed that patients on a 10‐week waiting list had a statistically significant increase in mean tumour diameter, the other did not, and both studies concluded that any observed increase in size was clinically inconsequential. Thus for BCC, a specialist opinion within 2 weeks of first referral is unlikely, in most cases, to make a difference to the outcome of treatment. SCCs account for around 20% of NMSC 11 and currently place a considerable burden on dermatology, histopathology, plastic surgery and radiotherapy departments. There is considerable variation in the significance of various subtypes of SCC. While the overall rate of metastasis from SCC has been estimated at around 2–3%, 22–24 the rate of metastasis in lesions evolving from solar keratoses (a condition estimated to affect some 25% of a Welsh population, 25 of which approximately 0·25% transform to SCC 25) is approximately 0·5%. 26 Transformation of Bowen’s disease to SCC is of the order of 4–6%, 27 but when this does occur, up to one third will metastasize. 28 Significantly higher rates of metastasis also occur in SCC arising on mucocutaneous surfaces, 29 in burn scars, chronic osteomyelitis sinuses or chronic ulcers, post‐X‐irradiation, 29, 30 or in inflammatory diseases such as discoid lupus erythematosus, lichen planus 31 and lichen sclerosus et atrophicus. 32 An extremely important group of patients with SCCs, with an 18‐fold increase in the rate of metastasis, consists of immunosuppressed renal transplant patients after some 3–7 years after immunosuppressive therapy. 33 SCC is also more likely to metastasize in patients with leukaemia or lymphoma, 34 but this does not appear to be the case with AIDS, 35 probably because this group of patients does not live long enough to develop SCC. Given that almost all SCCs occur in actinically damaged skin, 26 patients with small, slowly growing lesions in this clinical setting are unlikely to be disadvantaged clinically by a small increase in lesion size while on a waiting list, before treatment is undertaken. It is, however, clear that tumours in immunosuppressed patients, those that are rapidly growing, or arising in, for example, chronic scars or leg ulcers, should be seen quickly to reduce the possibility of metastasis. So how does this determine how we meet dermatological needs in the U.K.? The Government White Paper indicates that everyone suspected of having cancer will be able to see a specialist within 2 weeks from the time the GP has requested an appointment. It is clear that most patients with BCCs and SCCs are unlikely to be significantly disadvantaged by a waiting list of a couple of months. Alternatively, providing more dermatologists may be part of the answer. However, in Exeter, where consultant staff doubled over a 4‐year period, the waiting list has also doubled over a similar period. 2 A more pertinent strategy may be to ensure that GPs and other non‐dermatological specialists are better educated in identifying those NMSCs that are more likely to metastasize, and to refer these urgently to dermatologists. More effective prespecialist screening would represent a better use of scarce resources than the current proposal to have all potential NMSCs seen by a dermatologist within 2 weeks.