The number of skin cancer clinics functioning within Australia’s primary care environment is increasing rapidly, and significant concerns have been raised about the type and quality of work done by some doctors in some clinics.
Mainstream general practice is threatened by perceived fragmentation, and specialist practice in dermatology and plastic surgery is threatened by encroachment into their domains of practice.
We propose an agenda of training, standards, accreditation, audit and research to ensure that skin cancer clinics provide optimal health outcomes for patients.
The recent report of a patient who attended a skin cancer clinic in New South Wales in 2002, and apparently failed to have a melanoma diagnosed, and then sued his attending practitioner, sends a chill through every doctor who has ever assessed a pigmented skin lesion.1 Although settled out of court, this case highlights the clinical challenges of screening for and diagnosing skin cancer, and throws into sharp relief the issue of quality and safety in skin cancer clinics in Australia.
In the Newcastle Herald in July 2005, Emeritus Professor Bill McCarthy of the Sydney Melanoma Unit is quoted as saying “I want to make it clear that I believe some clinics are very careful and do good work”. However, he also expressed concern that quality across the clinics was patchy:
Obviously some people have seen an entrepreneurial opportunity and some clinics have been put together by non-medical people who have simply advertised for doctors to work for them. The staff of some clinics do not have any specialised training: they may have just qualified or they may be overseas practitioners. Some fancy themselves as surgeons and maybe some were in other countries but they may not meet Australian standards. There is no quality control and no accreditation scheme. There are some who have come to me for advice. They might tell me they are going to work in a skin cancer clinic in a country town, for example. They sit in on my clinics for a day and, while that isn’t training, it’s better than nothing.1
Skin cancer is by far the most common cancer in Australia. The most common and important skin cancers are basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma. In 2002, there were estimated to be 374 000 cases of BCC plus SCC.2 The age-standardised incidence of BCC alone in men was 1150/100 000; more than 10 times that of prostate cancer, the next most common cancer.2 Most BCCs and SCCs occur in older Australians, causing considerable morbidity, but little mortality. In 2000–2001, they were also the most expensive cancer to treat, costing $264 million, followed by breast cancer at $241 million.3 Melanoma is the most common cancer among those aged 15–44 years, and the second most common cause of cancer death in that age group, and it accounts for 3% of all cancer deaths in all ages (1199 deaths in 2001).2
Skin cancers are the most common cancers managed by general practitioners, with more than 800 000 patient encounters each year.3 While historically GPs have managed most skin cancers,4 in recent years, with the rapid growth of “skin cancer clinics”, there has been a dramatic change. Little is known about these clinics; some include large “corporate” chains and others comprise smaller independent operators. Anecdotally, most doctors working in these clinics seem to be GPs, or at least non-specialist doctors, from a variety of backgrounds.
Some concerns have been raised about the type and quality of work performed within these clinics from other sectors of the profession.5 The pros and cons of “the fragmentation of general practice”, typified by skin cancer clinics, travel medicine clinics, women’s health clinics and others have been considered previously.6
Currently, in Australia, there are:
no barriers to working in skin cancer medicine in primary care;
limited training opportunities for generalist doctors wanting to do this work (and no formal award courses);
no opportunities for skin cancer clinics to be accredited against defined standards; and
no quality framework to support this work.
In August this year, the Skin Cancer Society of Australia was formed to provide one mechanism to redress some of these deficiencies (http://www.skincancersociety.com.au).
Two of us (A D, P B) have worked in the skin cancer field for over 20 years, and A D has provided formal training for 15 years. When one of us (D W) decided to start working in this field at the beginning of 2005, there was no barrier to taking a position in a skin cancer clinic, and no formal assessment of competency. There was also no barrier to accessing the Medicare Benefits Schedule (MBS) item numbers that relate specifically to the management of skin cancer, including some that relate to fairly significant plastic surgical procedures. There were no easily accessible training opportunities, or postgraduate awards for general practitioners in skin cancer medicine. Furthermore, as skin cancer clinics are demonstrably not general practices, they cannot be accredited through the mechanisms that apply to Australian general practice.
It is unclear whether the concerns expressed by other sectors of the profession5 lie in the age-old debate “GPs versus specialists”, or whether it is “skin cancer clinic doctors versus the rest”. Perhaps it is some of both. Certainly, there is real concern among mainstream general practice6 that skin cancer clinics are an expression (or the cause of) fragmentation, and there is real concern from dermatologists and plastic surgeons about encroachment on their domains of practice.
Without doubt, some dermatologists believe that they are the doctors best placed to diagnose and manage patients with skin cancer. However, there are hardly enough dermatologists to cope with current demand for their general services, let alone enough to manage the majority of skin cancers in Australia. Furthermore, some plastic surgeons believe that patients receiving surgical treatment for skin cancer should be treated exclusively by them, but the geographic distribution of dermatologists and plastic surgeons in Australia precludes their managing most patients. The perception may exist among some GPs that skin cancer doctors are taking a lucrative (procedural) aspect of their practice away. At least some of this debate seems to be vested in professional self-interest, rather than a dispassionate consideration of what is best for the patient.
Most patients with skin cancer can be competently diagnosed and treated by appropriately trained, non-specialist primary care physicians, whether they are working in skin cancer clinics or in mainstream general practice.7,8 We also believe that consultants, such as dermatologists and plastic surgeons, have a crucial role to play in helping manage the more complex cases, as well as providing training. However, much more needs to be done if we are to collectively ensure that patients enjoy maximal health outcomes, and that doctors are well trained and supported.
An academic unit has been formed in the School of Medicine at the University of Queensland and this group is now developing an integrated suite of programs, ranging from educational units suitable for continued professional development to a masters degree in skin cancer medicine. These programs are being prepared in consultation with professional groups, and we welcome engagement with all interested parties.
The Skin Cancer Society of Australia is well positioned to play an important role in organising and advocating for doctors who have a special interest in skin cancer medicine. The Society is also developing a set of standards for skin cancer medicine in primary care (including the role of imaging systems). Engagement with other sectors of the profession (Royal Australian College of General Practitioners, Australian College of Rural and Remote Medicine, Australian College of Dermatologists, and the Australian Society of Plastic Surgeons) will be critical, as will engagement with the Australian Government Department of Health and Ageing.
We call on the Department of Health and Ageing to urgently convene a representative working party to consider how skin cancer clinics (including those located within mainstream general practice) can be brought within some form of accreditation framework. One option might be to consider making some Medicare Benefits Schedule item numbers only available to doctors working within an accredited practice, and who have completed some form of approved specific training. There are precedents for this suggestion, including in acupuncture and in mental health.
We call on corporate groups involved in skin cancer medicine to become openly involved in this debate, and to contribute hard data to it. While recognising the legitimate competitive business activity of many of these groups, we suggest that there is also a common interest that needs to be fostered to further the legitimacy of the industry as a whole.
Lastly, we need data. The current debate is based on anecdote and opinion. We urgently need data to inform this important debate, and so we need a research agenda. This agenda, as well as seeking to answer important clinical research questions, also needs to have a strong health systems focus. We can then define what is currently happening in skin cancer medicine in primary care, why it is happening, why very large numbers of patients continue to use skin cancer clinics, why more and more doctors are choosing to work in them, and how we can best ensure the very best health outcomes for our patients. As a profession we cannot afford to aim for anything less.
- 1. Father wins case, loses life to cancer. Newcastle Herald 2005; 2 July.
- 2. Australian Institute of Health and Welfare. Cancer in Australia 2001. Canberra: AIHW and Australian Association of Cancer Registries, 2004. (AIHW Catalogue No. 23.) Available at: http://www.aihw.gov.au/publications/index.cfm/title/10083 (accessed Nov 2005).
- 3. Australian Institute of Health and Welfare. Health system expenditures on cancer and other neoplasms in Australia, 2000-01. Canberra: AIHW, 2002 (Health and Welfare Expenditure Series No. 22). (AIHW Catalogue No. HWE 29.) Available at: http://www.aihw.gov.au/publications/index.cfm/title/10129 (accessed Nov 2005).
- 4. National Cancer Control Initiative 2003. A report by the NCCI Non-melanoma Skin Cancer Working Group. In: Staples MP, editor. The 2002 national non-melanoma skin cancer survey. Melbourne: NCCI, 2003.
- 5. Surgeons warn over skin cancer clinics. Herald Sun (Melbourne) 2005; 26 Jul.
- 6. Wilkinson D, Dick M-L B, Askew DA. General practitioners with special interests: risk of a good thing becoming bad? Med J Aust 2005; 183: 84-86. <MJA full text>
- 7. Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol 2000; 143: 1016-1020.
- 8. Osborne JE, Chave TA. Comparison of diagnostic accuracy for cutaneous malignant melanoma between general dermatology, plastic surgery and pigmented lesion clinics. Br J Dermatol 2003; 148: 252-258.
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