Implementing a Timed Skin Cancer Diagnostic Pathway: Guidance for Local Health and Care Systems

Overview

This specialist Guidelines summary covers NHS England advice on the implementation of a timed skin cancer diagnostic pathway. Best practice timed pathways aim to shorten diagnosis times, reduce variation, and improve the experience of care. This guidance sets out how the diagnosis of squamous cell carcinoma, malignant melanoma, and rare skin cancers can be achieved within 28 days in the urgent suspected skin cancer referral pathway.

This is a summary of the guidance for secondary care oncology teams. For further information, please refer to the full guideline. 

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The Faster Diagnosis Standard

• The Faster Diagnosis Standard (FDS) should ensure people are told they have cancer, or that cancer is excluded, within a maximum of 28 days from referral. The new standard is intended to:
  • reduce the time between referral and diagnosis of cancer
  • reduce anxiety for the cohort of people who will be diagnosed with cancer or receive an ‘all clear’
  • reduce unwarranted variation in England by understanding how long it is taking people to receive a diagnosis or ‘all clear’ for cancer
  • represent a significant improvement on the current 2-week wait to the first appointment target and a more person-centred performance standard.

28-day Best Practice Timed Pathway

Detailed Information

Referral from General Practice

• Urgent suspected skin cancer GP referral pathway should be used for people who meet the criteria in the NICE Guideline on suspected cancer (NG12) for urgent suspected cancer pathway referrals [1]
• For genital lesions suspected to be cancer, local referral pathways should be agreed upon, which may be via specialist genital skin, urology, or gynaecology suspected cancer clinics [1]
• The national cancer waiting times monitoring dataset sets out consultant upgrade rules, including from non-GP scenarios such as advanced nurse practitioner, accident and emergency, and acute settings. This needs to be locally agreed between commissioners and providers and in the context of appropriate training and local governance frameworks [1]
• A minimum dataset should be agreed locally with GPs to accompany the referral and facilitate the clinical assessment, which includes: [2]
  • symptoms in line with NG12, including:
    • location
    • size and shape
    • duration
    • evolution
    • bleeding
    • itching
  • ultraviolet exposure
  • family history
  • past medical history of skin cancer
  • chronic skin inflammation
  • immunosuppression
  • demographics
  • anticoagulant status
  • World Health Organization performance status
  • comorbidity
  • prescribed medication (when auto populated in practice IT system)
  • presence or not of pacemaker or other internal electronics
  • any known allergies
  • need for interpreter
  • mental capacity to consent
  • other needs
• If there is suspicion of melanoma, the minimum dataset may also include information about asymmetrical shape, border irregularity, colour irregularity, diameter >6 mm, the evolution of the lesion, and bleeding or itching [2]
• If referring to a teledermatology service for virtual assessment, the minimum dataset should also include macroscopic and dermoscopic images to an agreed-upon standard and format [3]
• Primary care clinicians should inform people that they are being referred for an urgent suspected cancer pathway, although they should also state that the vast majority of referrals result in non-cancer diagnoses. [4]

Clinical Assessment

• Clinical assessment will be undertaken by a suitably experienced clinician in a recognised skin cancer dermatology service who is part of the skin cancer multidisciplinary team [5]
• One-stop clinics or ‘super-clinics’ may be used to provide coordinated assessment and treatment to reduce visits and improve patient experience [5]
• An alternative approach is high-volume single-lesion ‘spot’ clinics offered in community settings to reduce unnecessary hospital attendances. A similar model can be used in a hospital setting [5]
• Teledermatology skin lesion diagnostic services may be used as the first point of contact and clinical assessment. Clinicians should be suitably trained and experienced in teledermatology and teledermoscopy and supported by a systematic quality assurance process [6]
• If there is clinical uncertainty after reviewing the images, a face-to-face assessment should be offered in a timely manner to enable the 28-day timed pathway to be met. [6]

Communication with Patients

• Patients and carers are provided with all necessary information about what to expect with the confirmation of an appointment [7]
• This is particularly important if patients are likely to have same-day local anaesthetic skin surgery, when information about what this might involve and any relevant limitations such as driving afterwards should be included [7]
• Information about accessing necessary support for people with any disabilities or language barriers is essential [7]
• Preferences for the amount of information and when it is provided will vary, and therefore, a single point of contact may include: [7]
  • access to a caseworker or navigator to provide support throughout the pathway and outside of clinic times
  • signposting to charities and support services
  • information about carers attending appointments
  • offer follow up if patients do not receive confirmation of their appointment within the expected timescale
• When possible, continuity of caseworker or navigator should be provided to enable familiar contact and build trust. [7]

On Diagnosis

• A diagnosis of cancer (either a clinical or histology diagnosis) should be communicated through face-to-face contact unless otherwise explicitly agreed with the patient and clearly documented [8]
• Alternative communication agreed upon by the patient could include a telephone call, letter, or email [8]
• Communication about cancer should be between a doctor and the patient, and carer if required, supported by a clinical nurse specialist [8]
• Cancer tracking teams and clinicians should agree on a consistent approach for recording and tracking FDS data items, covering different communication methods [8]
• In this timed pathway, this can be done at the initial clinical assessment or in a follow-up clinic, which might be a face-to-face or telephone consultation, or in writing if the patient has agreed to this method of communication [8]
• When cancer is ruled out, information about relevant benign conditions should be considered [8]
• Telephone or written communication is particularly suited when a cancer diagnosis has been ruled out and reduces unnecessary hospital attendances when this is preferred by patients [8]
• Information on the clinical diagnosis given should be available in a format that patients would prefer, when possible (such as a written leaflet, email, or website), and presented in a way that they will understand, taking account of language, cultural, sensory, learning, or other needs [8]
• When cancer is ruled out or confirmed and communicated with the patient, the FDS pathway can be completed [8]
• Cancer waiting time (CWT) rules (including ‘clock start’, ‘adjustments’, and ‘clock stop’) are set out in the national cancer waiting times monitoring dataset guidance. [8]

Personalised Care and Support Planning

• Personalised care and support planning should be based on the patient and clinician(s) completing a holistic needs assessment (HNA), usually soon after diagnosis [9]
• The HNA ensures conversations focus on what matters to the patient, considering wider health and wellbeing, practical issues, and support, in addition to clinical needs and fitness [9]
• This enables shared decision-making regarding treatment and care options [9]
• Management of basal cell carcinoma should follow local and national guidelines and pathways. [10]

Surgical Excision

• Surgical excision may be included as part of a one-stop service at initial assessment, provided adequate time is allowed for consent. Some people will be booked for surgical excision on a routine dermatology surgery list, and others will be directed to specialist surgical services including plastic surgery, maxillofacial surgery, oculo-plastics, or other specialties following initial clinical assessment [11]
• Patients booked for dermatology surgery or referred to other specialties for surgery are likely to have been given a cancer diagnosis at the clinical assessment appointment. The FDS ‘clock stop’ can be completed at this point. Excision with intent to treat will be recorded as the first treatment and will complete the CWT 31-day first treatment standard [11]
• When a clinical diagnosis has not yet been given to the patient and a suspicious lesion (such as a clinically atypical melanocytic lesion) is to be fully removed to exclude or confirm cancer, at the point at which a decision to treat is agreed upon with the patient (recorded as ‘CANCER TREATMENT PERIOD START DATE’ in the CWT dataset) the FDS calculation will be stopped [12]
• Further information is available in the national cancer waiting times monitoring dataset guidance. [12]