UK incidence of the serious skin cancer melanoma is rising rapidly and action in primary care settings has potential to substantially improve early diagnosis and drive better outcomes for patients. Research from the Primary Care Unit in Cambridge is shaping diagnosis procedures in primary care which could deliver measurable reductions in mortality and morbidity amongst patients with melanoma.
Dr Fiona Walter, Principal Researcher in Primary Care Cancer Research at the Primary Care Unit, University of Cambridge, has focused on detecting melanoma in primary care since 2007, alongside other major studies on the role of primary care in cancer prevention, diagnosis and follow-up care.
Dr Walter’s work on melanoma, supported throughout by NIHR, now underpins the wide-ranging MelaTools programme of research. This current portfolio of studies has the overall aim of optimising early diagnosis of melanoma, in the UK primary care setting.
Differentiating melanomas from other pigmented skin lesions in primary care is challenging. Worldwide, the incidence of melanoma is increasing faster than any other cancer, with an approximate doubling of rates every 10-20 years in countries with white populations. In the United Kingdom the incidence of melanoma has quadrupled over the past 40 years; data from Cancer Research UK for 2013 reported 14,500 new cases and more than 2,500 deaths. Early detection is critical in reducing mortality and morbidity from melanoma, as stage 1 disease has five year survival rates of over 95% compared with 10-20% for stage 4 disease. Pigmented lesions are commonly presented in primary care consultations, so general practitioners need to be able to reassure the vast majority of people with benign lesions and rapidly refer those with suspicious lesions.
Most referred pigmented skin lesions are benign, so interventions to improve primary care clinicians’ diagnostic performance would reduce unnecessary referrals
– Dr Fiona Walter
Promising early work enabled Dr Walter to take forward a comparison of diagnostic systems for suspicious skin lesions through the NIHR funded MoleMate trial. The trial examined the effect of adding a diagnostic aid, the MoleMate system, to ‘best practice’, to manage potentially suspicious pigmented lesions in primary care. This work was reported in 2012, and was awarded the RCGP Cancer Paper of the Year the following year.
Methods – MoleMate trial
Set in 15 general practices in eastern England, this Randomised Controlled Trial recruited adults with pigmented skin lesions not immediately recognisable as benign. Patients were assessed by GPs using best practice (clinical history, naked eye examination, seven-point checklist) either alone (control) or with MoleMate (intervention). The primary outcome was appropriateness of referral: reference standard diagnosis was recorded for all trial lesions. Secondary outcomes related to clinician diagnostic performance and patient anxiety.
Findings – improving management of suspicious skin lesions
The MoleMate trial remains the largest undertaken for timely detection of melanoma in primary care worldwide to date. The trial showed that improving the management of pigmented skin lesions can be delivered by changes in general practice systems that ensure the routine application of the existing ‘seven point checklist’, rather than by new diagnostic aids. Further improvements could be possible through better follow-up of all non-referred patients with lesions using standard ‘safety-netting’ procedures.
GP and patient interventions to improve detection of melanoma in primary care – the MelaTools programme
Dr Walter’s 2013 NIHR clinician scientist award enabled the development of the MelaTools programme. MelaTools studies are:
- comparing the effect of the use of electronic clinical decision support (‘melanoma-eCDS’) against usual GP management on melanoma thickness at diagnosis- the first study investigating whether a GP intervention can affect timely cancer diagnosis at national level;
- identifying people at higher risk of melanoma, and assessing whether these people can use a smartphone to self-monitor their moles and identify potentially important changes over time.
Studying melanoma allows us to use changes in tumour thickness at diagnosis to assess whether changing GP behaviour can produce a shift in cancer outcome.
– Dr Fiona Walter
Influencing the research agenda
As chair of the National Cancer Research Institute (NCRI) Primary Care clinical studies group early diagnosis sub-group and member of NCRI Skin Cancer Clinical Studies Group, Dr Walter is able to shape research priorities in the UK.
About the PCU’s Cancer Group
Effect of adding a diagnostic aid to best practice to manage suspicious pigmented lesions in primary care: randomised controlled trial. BMJ 2012; 344: e4110
Walter F, Morris H, Humphrys E, Hal P, Prevost T, Burrows N, Bradshaw L, Wilson E, Norris P, Walls J, Johnson M, Kinmonth A, Emery Winthrop J.