Letters
Dermatology General medicine
Volume 188 - Issue 2

Diagnosing skin cancer in primary care: how do main-stream general practitioners compare with primary care skin cancer clinic doctors?

Author:  Jeffrey Keir

Med J Aust 2008; 188 (2): 125-126. || doi: 10.5694/j.1326-5377.2008.tb01545.x
Published online: 21 January 2008
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To the Editor: Youl and colleagues are to be commended for their research into the performance of special-interest skin cancer clinicians.1 However, the conclusion that the performance of general practitioners and skin cancer doctors in the diagnosis of skin cancer is similar is highly questionable.

To truly compare the two groups and their diagnostic accuracy, it must be established that the participants were representative of the groups they are supposed to represent. The fact that the participating GPs were largely self-selected, perhaps on the basis of their personal interest in the subject, was a potential flaw that the authors acknowledge.

Further, an examination of diagnostic accuracy should also take into account whether the lesions found were of similar type, size and stage. There was no determination of any qualitative differences (eg, in size or thickness) between the tumours seen and diagnosed by the two groups. When a patient presents, specifically, with a large, tender, hyperkeratotic squamous cell carcinoma (SCC), there is no real test of diagnostic skills. On the other hand, detecting a small early posterior-thigh melanoma or a superficial BCC on a whole body examination is a challenge. Overall, one would expect at least two to three BCCs to be diagnosed for each SCC found2 — however, in the study by Youl et al, GPs found a similar proportion of each type of lesion, suggesting that perhaps a large number of BCCs were not being detected at all in the GP group.

The lower incidence of whole body examinations in the GP group suggests that a higher proportion of asymptomatic lesions may have been missed by the GP group and thus not included in their sensitivity/specificity data. This possibility could have been examined by noting the site of lesions found: identification and diagnosis of lesions in areas covered by clothing or footwear may be more likely on whole body examination.

Although Youl et al reported that the diagnostic sensitivity for melanoma among skin cancer clinic doctors was twice that of GPs, a re-examination of the data with all of the above in mind may well reveal that skin cancer clinic practitioners are performing even better than suggested.

That being said, the number of melanomas found per week by the skin cancer group (0.25 melanomas/doctor/week) in the study by Youl et al is much lower than in our own dedicated primary care skin cancer clinic (1.47 melanomas/doctor/week, based on audit data gathered between February and September 2007).

Good medical care relies on accurate diagnosis and appropriate treatment, and the earlier the diagnosis is made, the less costly and less invasive the treatment and the greater likelihood of a cure. Surely we should all be working together — skin cancer clinic practitioners and GPs, alike — towards achieving optimum outcomes for our patients. To that end, a wider range of higher education in skin cancer medicine is being encouraged by the University of Queensland’s Master of Medicine program3 and the Skin Cancer College of Australia’s fellowship program,4 and bodies such as the Skin Cancer Society of Australia and the Royal Australian College of General Practitioners have been working together to introduce an accreditation process for those practising primary care skin cancer medicine.5,6

Author

  • Jeffrey Keir1
  • 1. Northern Rivers Skin Cancer Clinic, Ballina, NSW.

Correspondence: nrsccweb@ceinternet.com.au

References

View this article on Wiley Online Library