Cutaneous melanoma (CM) is an aggressive tumor of the skin melanocytes. It is a growing health concern with a globally increasing incidence in fair-skinned populations over the last few decades [
To minimize delay between presentation, diagnosis, and treatment of CM, the Danish Health and Medicines Authority implemented a national fast-track referral system (FTRS), which also includes that the surgical management of primary melanoma is according to national clinical guidelines. Other skin malignancies, such as basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), are not intended to be referred through this system. The aim of the national FTRS was “
The Department of Plastic Surgery & Breast Surgery, Zealand University Hospital, provides a regional health service to a population base of approximately 820.000 inhabitants in Zealand Region in Denmark, representing nearly 15% of the country’s total population. The incidence of melanoma in Zealand Region in a five-year period in 2010 to 2014 increased from 245 to 445 patients, including MIS [
In the Danish health care system, the general practitioners (GPs) function as gatekeepers for consultant dermatologists, plastic surgeons, and plastic surgery departments, where treatment of CM is performed. The Danish national FTRS for skin lesions suspicious of melanoma implies that a patient who presents with a lesion suspicious of CM is offered an excision biopsy in secondary care within six days. This allows confirmation of the diagnosis within two weeks and permits the second stage of definitive wider excision and sentinel lymph node biopsy (SLNB) to be based on tumor characteristics such as the Breslow thickness, mitotic activity, or presence of ulceration, which is then offered within nine days. If SLNB is positive for metastasis, the patient is offered the third stage comprising radical lymph node dissection within two weeks.
Our plastic surgery department receives referrals regarding lesions suspicious of melanoma from GPs, dermatologists, private plastic surgery clinics, or other specialties for clinical evaluation and treatment. If a biopsy is made prior to the referral, the patients are offered further treatment in the department depending on the histological examination of the biopsy.
The aim of this study was to analyze the referral patterns of suspicious melanocytic skin lesions to our department in the FTRS. We hypothesize that a relatively large proportion of the referrals will present with skin lesions other than CM, leaving room for improving diagnostic accuracy in the primary health care sector. Therefore, the objective was to characterize the referrals in the FTRS of suspected or classified CM, in order to clarify from which health services the referrals originate and how many of the referred patients had in situ melanoma (MIS), invasive cutaneous melanoma (CM), non-melanoma skin cancer (NMSC), or benign lesions.
Patients referred in the FTRS to the Department of Plastic Surgery and Breast Surgery in Zealand University Hospital, because of a lesion suspicious of CM or with a biopsy-verified CM, were registered prospectively in a population-based cross-sectional study of the Zealand Region consisting of approximately 820.000 inhabitants in Denmark.
This study included patients over a 1-year period in 2014, who had undergone surgical biopsy in general practice, by dermatologists, in private plastic surgery clinics or in other medical specialties and who were referred to our department for further treatment. Patients who were referred by the above health services because of a suspicious lesion without a biopsy prior to the referral were also included. In the first visit to the outpatient clinic, the patient was examined clinically and by manual dermatoscopy, and a total body skin examination was performed. Also, the patient was offered an immediate excision biopsy under local anesthesia, if a biopsy was not performed prior to the referral. The patients were scheduled after two weeks for suture removal and results of histology. Patients who did not show up to the consultation or who did not want to have an excision biopsy performed and patients with metastatic melanoma of unknown primary origin were excluded from the study.
Variables are patient age, sex, anatomical location of the lesion, tumor characteristics, and from which health services the referrals originated were registered, along with whether or not a biopsy had been performed prior to referral. All cases were coded as in situ melanoma (MIS), invasive cutaneous melanoma (CM), non-melanoma skin cancer (NMSC), or benign lesions.
The histological examinations of all the tumor biopsies were conducted at the Department of Pathology, Roskilde University Hospital.
All data were tested for distribution of normality and treated statistically accordingly. Comparison between groups was tested by two-tailed
A total of 565 patients were prospectively registered as referred to the center in the FTRS for skin lesions suspicious of melanoma (Table
Results of referrals in the fast-track referral system for skin lesions suspicious of melanoma.
Females | Males | Total | | |
---|---|---|---|---|
| 293 (52.7) | 263 (47.3) | 556 | <0.05 |
Age (mean ± SE) | 57 ± 1.0 | 60 ± 1.0 | 58 ± 0.7 | <0.05 |
CM | 170 | 142 | 312 | <0.05 |
In situ (%) | 23 (56.1) | 18 (43.9) | 41 | ns |
NMSC | 13 | 16 | 29 | ns |
Benign | 86 | 85 | 171 | ns |
CM: cutaneous melanoma.
NMSC: non-melanoma skin cancer.
Most of the patients (393; 70.7%) were referred due to a suspicion of CM and had an excision biopsy taken on the first visit, whereas 159 (28.6%) patients were referred due to a biopsy-verified CM.
A total of 312 patients (56.1%) were eventually diagnosed with CM, significantly more females than males (
Origin of the referrals in the fast-track referral system and the proportion of diagnosed CM and diagnostic accuracy.
GP | Derm. | PS | Other | Total | |
---|---|---|---|---|---|
Referrals | 88 | 441 | 5 | 22 | 556 |
(i) Without biopsy | 55 | 321 | 0 | 17 | 393 |
CM diagnosed with biopsy prior to referral | 31 | 106 | 5 | 5 | 113 |
CM verified with biopsy after referral | 16 | 145 | 0 | 4 | 199 |
CM in total | 47 | 251 | 5 | 9 | 312 |
CM: cutaneous melanoma.
Derm.: dermatologist.
PS: plastic surgeon.
When Breslow thickness was analyzed according to age groups and sex (Table
Age, gender, and Breslow thickness (%).
Age | Females | Males | ||||
---|---|---|---|---|---|---|
≤1 mm | >1–4 mm | >4 mm | ≤1 mm | >1–4 mm | >4 mm | |
20–40 | (11.8) 20 | (1.8) 3 | 0 | (4.2) 6 | (2.8) 4 | 0 |
41–55 | (26.5) 45 | (7.6) 14 | 0 | (11.3) 16 | (5.6) 8 | (0.7) 1 |
56–70 | (19.4) 33 | (5.3) 9 | (1.8) 3 | (24.6) 35 | (12.7) 18 | (1.4) 2 |
>70 | (11.2) 19 | (8.2) 14 | (5.3) 9 | (16.9) 24 | (13.4) 19 | (4.2) 6 |
| ||||||
Total | (68.8) 117 | (22.9) 40 | (7.1) 12 | (57.0) 81 | (34.5) 49 | (6.3) 9 |
Distribution on Breslow thickness of referrals originating from GPs or dermatologists when biopsy is performed prior to and after referral.
Referrals | Breslow thickness | |||
---|---|---|---|---|
≤1 mm | >1–4 mm | >4 mm | Unclassified | |
GP | ||||
+ biopsy | 21 | 7 | 2 | 1 |
÷ biopsy | 9 | 4 | 3 | 0 |
Dermatologist | ||||
+ biopsy | 58 | 40 | 4 | 4 |
÷ biopsy | 89 | 45 | 11 | 0 |
÷ biopsy: biopsy performed after referral.
All of the included patients were seen after referral within the recommended time period and there was no difference in timing according to who was referring the patient. Furthermore, all patients diagnosed with CM had a definitive wider excision performed based on tumor characteristics in accordance with national guidelines for treatment of melanoma, including SLNB and radical lymph node dissection, if these were indicated.
This is the first population-based cross-sectional study in Denmark that provides insight into the diagnostic accuracy of referrals of patients with skin lesions suspicious of melanoma, and the referring physicians’ ability to differentiate between CM, NMSC, and benign lesions. Of all the referred patients, a total of 312 patients (56.1%) were diagnosed with CM and 41 patients were diagnosed with MIS (7.4%), whereas 200 patients had NMSC or benign lesions (35.9%). The FTRS can improve rapid access for patients with CM, but only when used appropriately due to increased education, clear communication, and improved technology for consistent detection of cancers [
In our presented data, most referrals (441; 79.3%) were from dermatologists and only five from plastic surgeons (Table
Cutaneous melanoma is still a skin cancer with the highest mortality despite all the preventive and therapeutic efforts, and this is also despite CM being less common than other non-melanoma skin cancers [
By using this referral system, it is understandable and appropriate that some referrals will be made on the basis of doubt, especially if the referring physician is less experienced. Also, some physicians may experience pressure from patients and their concerns of increased waiting times for having routine referrals [
Recent evidence has shown that the increase in the incidence of CM is due to a generally higher awareness of skin cancer and the improved strategies for early recognition and diagnosis of suspicious melanocytic lesions. This is resulting in an increasing incidence of early stage melanomas [
A limitation to our study is that this is a single center study based on the figures of one region of the country. However, Denmark is a relatively homogenous country with an even distribution of CM [
The study was reported to and approved by the Danish Data Protection Agency (Reference no. 2008-58-0020/15-000241).
Authors have no conflict of interests to declare.