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Skin cancer surgery on referral

Letter to British Medical Journal re melanoma

Lets get back to basics managing melanoma

I find the debate about sentinel node biopsy puzzling.1 Clinicians are getting bogged down with this question while the fundamentals of managing cutaneous melanoma are being neglected. A recent Australian study299 showed that doctors perform poorly in key aspects of managing this aggressive tumour.

 

Only a third of doctors excised cutaneous melanoma with the margins recommended by the Australian guidelines - a third used larger margins and, more worrying, a third used narrower margins. Most doctors failed to check the skin at follow-up, and they often diagnosed suspicious lesions by biopsy not local excision. Australian surgeons are slow to acquire dermoscopic skills that improve early diagnosis of melanoma. A patient with a thin melanoma is more likely to develop another cutaneous primary than metastatic disease. Yet dermoscopy and skin checks are often neglected.

 

If surgeons used time spent doing the sentinel lymph node biopsy in routinely examining the skin at follow up, there would be a tangible gain for our patients. In contrast, a procedure with a 10% incidence of complications271 which does not improve five year survival,300 is hardly a tangible gain.

 

Let us get back to the basics. Let’s offer our patients skin checks for life, ensure dermoscopy is a routine part of this examination, and excise suspicious lesions rather than biopsy them to gain histology. Most importantly, let’s give our patients with invasive melanoma a minimum 10 mm margin of normal skin rather than skimp.