Should I see a skin cancer specialist?

This page is about guidelines for seeing a non melanoma skin cancer specialist. If you are looking for the guidelines for melanoma skin cancer, then use this link to take you to the right page.

It can be very difficult for GPs to decide who may have a suspected cancer and who may have a minor problem that will go away on its own. With many symptoms, it is right that your GP asks you to wait to see if they get better or respond to treatment such as antibiotics. If GPs referred everyone who came to see them to a specialist immediately, the system would get jammed and those needing urgent appointments wouldn't be able to get them. But there are particular symptoms that mean your GP should refer you to a specialist straight away.

The National Institute for Health and Clinical Excellence (NICE) and the Scottish Government have produced guidelines for GPs to help them decide which patients need to be seen urgently by a specialist. A specially trained GP might look after you in the community. There is guidance on when this can happen. But if there is any doubt you will be referred to a specialist skin doctor called a dermatologist. While reading these guidelines, it is important to remember the following key points about these types of skin cancers.

Basal Cell Cancer

• Is very common 
• Is slow growing 
• Does not tend to spread
• Is mostly found on the face, especially near the nose. Often it is a lump with shiny edges. It can have a sunken middle or may develop into an ulcer
• Is also known as a rodent ulcer

Squamous Cell Cancer

• Is rare in people under the age of 60 unless you have a condition that weakens your immune system such as AIDS. Or if you have had an organ or a bone marrow transplant and are taking medicines to stop rejection
• Has some specific risk factors
• Is most common in areas of skin exposed to the sun such as the head, neck, the back of the hands, and forearms
• Tends to be larger than 1cm (half an inch) wide and usually looks like a crusty, scaly ulcer. Or it may be bumpy and hard and develop into an ulcer

The symptoms that need an urgent referral within 2 weeks for squamous cell skin cancer include

• A hard, broken area of skin that is bigger than 1cm across, will not heal, and has definitely grown in size in 8 weeks
• Patients whose GP has taken a biopsy of a skin lesion and it has been confirmed as squamous cell skin cancer
• Any new abnormal appearances on the skin, or existing ones that are getting bigger, in anyone who has had an organ transplant (which means you are at higher risk of skin cancer)

Your doctor may also refer you to a skin specialist if you have a skin condition that won't go away and is not responding to treatment.

Basal cell skin cancers do not usually need an urgent referral within 2 weeks. But the guidelines state that if your GP suspects you have a basal cell cancer then you should have a non urgent referral to a specialist.

If you are concerned that your GP is not taking your symptoms as seriously as you think they should, you could print this page and take it along to an appointment. Ask your GP to talk it through with you and then you may be able to decide together whether you need to see a specialist and if so, how soon. There is information about preventing skin cancer in this section.

In 2006 the National Institute for Health and Clinical Excellence (NICE) issued guidance called Improving Outcomes For People With Skin Tumours Including Melanoma. In May 2010 the management of low risk basal cell carcinoma section was reviewed and the guideline was updated. This guidance recommends that all cancer networks set up two levels of multidisciplinary teams.

The multidisciplinary team (MDT) is a team of health professionals who work together to decide on the best way to manage your care. The MDT can include many different health professionals including 

• Skin specialists (dermatologists)
• Plastic surgeons 
• Cancer specialists 
• Doctors who specialise in reading X-rays and scans (radiologists) 
• Specialist nurses
• GPs with a special interest in skin cancer 
• Physiotherapists 
• Occupational therapists 
• Cosmetic camouflage advisers 
• Doctors who make a diagnosis from tissue specimens (histopathologists)

The two levels of MDT are the Local Hospital Skin Cancer Multidisciplinary Team (LSMDT) and a Specialist Skin Cancer Multidisciplinary team (SSMDT). LSMDTs are likely to be in cancer units in district general hospitals. SSCMDTs are more likely to be in larger hospitals that have cancer centres or plastic surgery centres. All of the members of these multidisciplinary teams have specialist training in skin cancer. The teams meet regularly. There may be more than one of these teams if you live in an area with a large population.

Everyone with suspected skin cancer will be seen by a member of one of these teams. For basal cell cancers (BCC) that are unlikely to come back, you might be seen by your GP, if they are a member of the LSMDT.

The aim of the 2010 update was to make it clear who is allowed to remove basal cell cancers in community clinics and what training they need. Only GPs or specialist nurses who have had training should remove these cancers. 

Your GP may refer you to the local skin cancer multidisciplinary team (LSMDT) if

• You have basal cell cancer that is at higher risk of coming back or has come back
• You have squamous cell skin cancer or melanoma
• It’s not certain which type of skin cancer you have

Your GP, or doctor from the LSMDT, will refer you to the specialist skin cancer multidisciplinary team (SSCMDT) if

• You have a rare skin cancer
• You have squamous cell cancer or melanoma that is at higher risk of coming back or has come back
• You have any type of skin cancer that has spread to another part of your body
• You need treatment that the LSMDT does not provide
• You are taking part in a clinical trial
• You live close to the SSMDT, in which case it will act as both your local and specialist centre

As this is a change in how services are organised it may take some time before this reorganisation is completed. The guidelines for GPs about who should be referred to a specialist are still relevant. If you are concerned that a multi disciplinary team is not looking after you, do ask about it. It may be that you have only seen one specialist, but the team have still got together with your test results and case notes to discuss the best treatment options for you.