Multidisciplinary Pigmented Lesion Clinic at Auckland District Health Board: impacts on melanoma diagnosis and treatment outcomes
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article
Multidisciplinary
Pigmented Lesion Clinic
at Auckland District
Health Board: impacts on
melanoma diagnosis and
treatment outcomes
Ken Hiu-Kan Ip, Aravind Chandran,
Isaac Cranshaw, Alex Ng, Ann Giles, Karen Agnew
ABSTRACT
AIM: To investigate the outcomes and effect of a multidisciplinary ‘see and treat’ pigmented lesion
clinic, run jointly by dermatology and general surgery, on the diagnosis and treatment of melanoma at
Auckland District Health Board (DHB).
METHOD: All patients attending the newly established Pigmented Lesion Clinic (PLC) between 1 March
2019 and 31 August 2019 were included in the study. They were compared against a retrospective
cohort of patients seen for suspected or biopsy-proven melanomas during the same corresponding
period in 2016.
RESULTS: 251 new patients attended the PLC, compared to 148 new patients seen at Auckland DHB in
2016. There was a significant reduction in proportion of pigmented lesions requiring biopsy (35.2% vs
64.3%, particle to be a melanoma, these patients would waiting times from referral through to wide return for a third appointment for wide local excision, performance of full skin local excision (WLE). A select group were check, delivery of skin cancer prevention also required to wait for an additional FSA education, clinical and histological diag- with general surgery to discuss sentinel nosis, benign-to-malignant ratio and Breslow lymph node biopsy (SNB). Alternatively, thickness. patients were referred directly to general To assess the impact of PLC on melanoma surgery and progressed through a similar diagnosis and treatment outcomes, a retro- step-wise process of multiple waiting lists spective review of patients referred for and appointments, which added to delays in suspected primary melanomas or further their diagnosis and treatment. Whichever management of biopsy-proven mela- specialty the patients attended was at the nomas in 2016 was performed to serve as discretion of their referrer. comparison. Specifically, the same param- In 2018, dermatology and general surgery eters were collected from clinical records pooled their resources together to establish of these patients referred to either derma- a novel multidisciplinary Pigmented Lesion tology or general surgery at Auckland DHB Clinic (PLC) at Auckland DHB - the only during the corresponding time period of 1 one of its kind in New Zealand. The PLC is March 2016 to 31 August 2016. modelled on a ‘see and treat’ service, where Statistical analysis was performed using patients referred for a suspected melanoma SPSS version 22. Chi-square analyses were attend their FSA with dermatology and/or used to test for significant differences in general surgery, and are offered excisional categorical variables. One-way ANOVA was biopsy at the same appointment. Full skin used to demonstrate significant difference in checks are performed on this high-risk mean waiting times. A p-value of
article Treatment outcomes for the retrospective A comparison of clinical and histological cohort in 2016, stratified by specialty, are information between patients attending PLC presented in Table 2. Depending on whether and patients in 2016 is presented in Table 3. patients were referred to dermatology or The PLC had a significantly reduced mean general surgery, there were significant waiting time from referral to attending differences in the mean waiting time to FSA (20 days vs 34 days, p
article 2.3:1 for patients who attended PLC and cantly shortened mean waiting times from patients in 2016, respectively. referral to attending FSA (22.6 days vs There was an increase in the proportion of 35.1 days, p=0.038), from FSA to excisional patients receiving full skin checks in the PLC biopsy (2.2 days vs 21.3 days, p
article
Discussion 2016, when 48.4% of suspicious pigmented
lesions reviewed by dermatologists, and
In this study, the PLC at Auckland DHB 88.7% reviewed by general surgeons,
has been shown to enhance the diagnosis required an excisional biopsy. These figures
and treatment of melanomas on multiple highlight not only the enhanced diagnostic
fronts. Importantly, the retrospective accuracy of the PLC, but also the important
analysis has highlighted a disparity in care role a dermatologist plays in the diag-
that was previously provided to patients nosis of pigmented lesions to minimise
with pigmented lesions, depending on the unnecessary surgery. Previously published
specialty they had been referred to. By rates of concordance in clinical diagnoses
establishing a multidisciplinary clinic run between GPs and dermatologists have
jointly by dermatology and general surgery, varied between 42% and 54%.8,9 The lower
Auckland DHB unified the melanoma patient concordance seen through PLC may be
pathway to ensure there is a single and equi- accounted for by a heightened index
table cancer pathway for all Auckland DHB of suspicion from GPs given the high inci-
melanoma patients. dence of melanoma in New Zealand, which
Of the 238 lesions referred by GPs to contrasts against the trained use of derma-
the PLC as suspected melanomas, only toscopy by the supervising dermatologists
35.2% proceeded to an excisional biopsy. with whom the general surgeons can
This proportion is further reduced from collaborate—dermatoscopy being an
Table 4: Clinical and histologic features of melanomas referred to Auckland DHB in 2016 and 2019.
2016 Pigmented Lesion
(n=28) Clinic (n=53)
Gender Male, n (%) 14 (50%) 28 (52.8%)
Female, n (%) 14 (50%) 25 (47.2%)
Age Mean (years) 64.9 63.5
Median (years) 63 66
Site Head/neck 5 (17.9%) 12 (22.6%)
Chest/abdomen 2 (7.1%) 4 (7.5%)
Back 9 (32.1) 13 (24.5%)
Upper limb 3 (10.7%) 11 (20.8%)
Lower limb 9 (32.1%) 13 (24.5%)
Histology Malignant melanoma 15 (53.6%) 28 (52.8%)
Melanoma in-situ 13 (46.4%) 25 (47.2%)
Breslow thickness Mean (mm) 0.93 0.96 p=0.94
Median (mm) 0.60 0.55
Waiting time Mean (days) 35.1 22.6 p=0.038
(referral to clinic)
Median (days) 25.0 16.0
Waiting time Mean (days) 21.3 2.2 particle
invaluable tool in correctly separating the timely access to FSA and treatment
melanomas from benign pigmented are further compounded by enhanced
lesions.10 compliance to the Ministry of Health’s
The diagnostic accuracy of the PLC is 62-day target for faster cancer treatment.14
further evidenced by the benign-to-ma- Whereas this target stipulates initiation
lignant ratio of 2.4:1. This compares very of treatment within 62 days of receiving a
favourably to internationally published high suspicion of cancer referral, patients
figures, which range from 4 to 14 for derma- treated through PLC had initiation of their
tologists and 20 to 40 for GPs.11 Maintaining treatment (WLE) on average 50.6 days after
a similar benign-to-malignant ratio from the referral date. For melanoma in-situ
2016 (2.3:1) through to PLC, while reducing and early stage invasive melanomas not
the proportion of lesions being biopsied, requiring adjuvant immunotherapy or radi-
represents the striking of an ideal balance ation therapy, surgical excision (WLE) also
between performing too many unnecessary represents completion of their treatment.
biopsies and performing too few biopsies at The advantages of the PLC model are not
the risk of missing a melanoma. To mitigate limited to enhanced diagnostic accuracy
the risk of the latter, the PLC allows for and timely access to treatment. The multi-
clinical follow-up of patients to monitor disciplinary model allows inter-specialty
for evolution or stability, if it is required, collaboration, which has led to improved
and provides all discharged patients with outcomes in other tumour streams.15,16
information regarding self-skin exam- Collaboration between dermatology and
ination, and that any changing pigmented general surgery allows all patients to
lesion warrants a further review with their have ready access to services provided by
GP. The reduction in unnecessary surgery general surgery, including surgery under
improves the efficiency of the service general anaesthetics where required and
and makes available otherwise expended SNB, without having to undergo previous
resources, such as surgical appointments, external referral pathways. There were too
to enable faster access to WLE for patients few patients requiring SNB in the retro-
with confirmed melanomas. Ultimately, this spective cohort to produce meaningful
translates into reduced patient morbidity comparison. The clinical nurse specialist
and reduced resource wastage while plays a key role in patient education, as well
achieving both time and monetary cost as being the point of contact and breaking
savings. bad news. The incorporation of a full skin
Establishment of the PLC and its ‘see and exam as a standard of care has led to initi-
treat’ model has led to significant reductions ation of treatment for otherwise undetected
in waiting time for patients to attend their skin malignancies in approximately one
FSA, to undergo excisional biopsy when out of five patients. The importance of total
there is clinical suspicion and to complete body examination, rather than focusing
treatment with WLE when melanoma only on the referred index lesion, has been
is confirmed. Rapid-access clinics dedi- highlighted previously by a UK study of
cated to pigmented lesions in England and over 1,800 patients, in which over one third
Ireland have similarly led to a reduction in of melanomas are detected as incidental
treatment times and consequent reductions lesions when the patient was referred for a
in tumour thickness and improved overall separate and often benign lesion.17
survival, though this was not observed in Notably, 28 invasive melanomas over a six
our study.5,12 In a New Zealand context, month period represent a small proportion
delivery of a see-and-treat clinic for skin of melanomas occurring within Auckland
lesions was first described by McGeoch et al DHB. In 2016, there were 216 new mela-
as a coordinated service between GPs and nomas reported within the same geographic
plastic surgeons in Canterbury.13 This, and area. Correspondingly, an Australian
data from overseas see-and-treat clinics study has previously shown that only
for non-melanoma skin cancers, have also 20% of melanoma patients are reviewed
reported reduced waiting times, as well as by dermatologists, with a significant
an enhanced perception of convenience proportion treated by combination of GPs
and overall satisfaction.6,7 The benefits of and surgeons.18 The PLC thus appears to be
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NZMJ 19 February 2021, Vol 134 No 1530
ISSN 1175-8716 © NZMA
www.nzma.org.nz/journalarticle
under-utilised. Increased awareness of the Auckland DHB, combined with a see-and-
PLC among GPs may increase patient access treat approach, has led to significant
to this publicly funded service. reductions in waiting times for FSA, exci-
In summary, a multidisciplinary approach sional biopsies and WLE. Other secondary
between dermatology and general surgery, and tertiary centres in New Zealand may
which incorporates dermatoscopic also consider adopting this novel model
assessment of pigmented lesions, has led of care, shown here to enhance multiple
to enhanced diagnostic accuracy and a facets of melanoma diagnosis and treatment
reduction in unnecessary surgeries. The outcomes.
development of a single pathway within
Competing interests:
Nil.
Author information:
Ken H-K Ip: Registrar, Dermatology Department,
Auckland District Health Board, Auckland.
Aravind Chandran: Dermatologist, Dermatology Department,
Auckland District Health Board, Auckland.
Isaac Cranshaw: General Surgeon, General Surgery Department,
Auckland District Health Board, Auckland.
Alex Ng: General Surgeon, General Surgery Department,
Auckland District Health Board, Auckland.
Ann Giles: Clinical Nurse Specialist, Dermatology Department,
Auckland District Health Board, Auckland.
Karen Agnew: Dermatologist, Dermatology Department,
Auckland District Health Board, Auckland.
Corresponding author:
Karen Agnew, Dermatology Department, Auckland District Health Board, Greenlane Clinical
Centre, 214 Greenlane West, Epsom, Auckland 1051, +64 9 307 4949 ext 26132
KAgnew@adhb.govt.nz
URL:
www.nzma.org.nz/journal-articles/multidisciplinary-pigmented-lesion-clinic-at-auck-
land-district-health-board-impacts-on-melanoma-diagnosis-and-treatment-outcomes
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