Leap in AU skin cancer clinic use

[Editor-in-Chief]

Leap in skin cancer clinic use24-Nov-2005
by Paul Smith

There has been a threefold rise in the proportion of patients opting for treatment at skin cancer clinics rather than traditional GP surgeries, according to preliminary results of a ground-breaking study into the clinics.

With the number of clinics exploding in the past decade, academics have argued they threaten traditional general practice by fragmenting standard care, as well as creaming off more lucrative work from general practice (Australian Doctor, "Row brews of specialisation?", 22 July).

Some 3600 patients were questioned as part of the Queensland Cancer Fund investigation, which aims to analyse the quality of care offered by the clinics and traditional general practices, and the case mix of patients.

The study found that between 2000 and 2001, 70% of patients visited their GP for detailed skin examination, with 10% opting for skin cancer clinics. But between 2002 and 2004, 54% of patients visited GP surgeries and 31% visited skin cancer clinics.

Professor David Wilkinson, deputy head of the University of Queensland school of medicine, who works one day a week at a Skin Alert clinic and is also researching the clinics, said the rising proportion of patients attending the clinics was most likely because they had greater access to them.

"There are more of them around, and I suspect that is what it reflects," he said.

Professor Wilkinson said the ?jury was still out? on whether the treatment provided by skin cancer clinics was any better or worse than that provided by GPs, but his own research suggested there was ?significant variation? in the care provided by both.

"Some practices are offering the highest quality of care, but some seem to require significant improvement," he said.

The push by some GPs towards specialisation has proved controversial. But Professor Wilkinson said while some GPs had found skin cancer clinics lucrative, he did not believe money was the prime motivator of most GPs adopting specialised practice.

"It is not at the moment an easy, triple-your-income sort of thing," he said. "I think a big factor is clinically, doctors want to develop a particular in-depth knowledge. [Also] There are no after-hours obligations and no weekend obligations."

The Queensland Cancer Fund research into the quality of care provided by clinics and GPs is due to be published next year. It is based on an analysis of 28 skin cancer clinics and 100 GPs working in Queensland.
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[Editor-in-Chief]

Cutting the mole toll

Clara Pirani
December 03, 2005

IT would be reasonable to assume that since skin cancer is the most commonly diagnosed cancer in Australia, doctors agree about the best way to treat it.

But a report that reveals Australians worried they have the disease are increasingly going to skin cancer clinics rather than their GP or a dermatologist has sparked a bitter dispute about who is best qualified to treat skin cancer.

The Queensland Cancer Fund, which raises money for cancer research, is conducting a study into the role skin cancers clinics play in the diagnosis and treatment of cancer.

The final results are expected next year, but a preliminary report released last week gave a hint of what's to come.

Researchers interviewed 3600 people in Queensland and found that in 2000-2001, 70 per cent went to their GP for skin examinations, 18 per cent went to a dermatologist and 10 per cent used a skin cancer clinic.



However, clinics are increasing their market share: between 2002 and 2004, 54 per cent went to a GP, only 14 per cent went to dermatologist and 31 per cent attended a skin cancer clinic. The findings prompted an angry response from skin cancer specialists, who say the clinics are almost exclusively run by GPs who are not adequately trained to diagnose skin cancer, or perform surgical procedures.

John Kelly, associate professor and dermatologist, is head of the Victorian Melanoma Service at the Alfred Hospital in Melbourne.

Kelly argues the advertising that promotes many clinics as "specialist" centres is misleading to consumers.

"Consumers should know that the clinics are run by GPs and should not expect specialists," he says. "In my view people should go to their family GP first, and then get a referral to a specialist."

He said GPs simply don't have the experience to diagnose all forms of skin cancer. "Some skin cancers are difficult to diagnose and they will get missed, and that's going to happen more often with people who are less trained and experienced.

"Dermatologists should diagnose skin cancer and plastic surgeons should perform the surgical procedures."

Signalling a matter of greater concern, Kelly claims GPs who run the clinics not only misdiagnose skin cancer but also perform almost five times the number of surgical procedures than dermatologists perform. Data shows that for every malignant lesion that GPs remove, they remove another 50 benign lesions that don't need to come off, he says – the reason being that GPs are less good at differentiating one type from the other. Trained dermatologists, by contrast, remove just nine benign lesions for every one malignant one.

"Skin clinics have been shown to have very different patterns of surgical procedures to plastic surgeons."

In some cases – depending on the type of biopsy performed to remove a lesion – stitches, a skin graft or a skin flap are needed to treat the wound. He said clinics usually perform "flap" procedures, "which generate a high return from Medicare."

Gold Coast-based plastic and reconstructive surgeon Ian McDougall says he has seen countless patients who have undergone unnecessary biopsies or skin flap procedures, often resulting in severe scarring.

"The number of skin cancers excised in the past five years has gone up by 37 per cent, which is probably normal with the increase in population and age. But the number of biopsies performed has gone up 128 per cent, and that's appalling," McDougall says. "They biopsy everything, which shows they don't know what they are doing."

McDougall believes the privately-run clinics are putting profit before patients. "Doctors earn $325 for doing a flap procedure, about $200 more than if they just removed the lesion."

McDougall says he has seen patients with excessive scarring caused by poor surgical techniques.

"Far too many unnecessary procedures are performed, often without any knowledge of the basic fundamentals of flap repair and excision techniques. And far too many are not removed properly, requiring a second procedure on the same lesion. Plastic surgeons study for years to perfect these techniques and GPs just don't have the training."

However, Chris Mitchell, chairman of the Royal Australian College of General Practitioners national rural faculty, insists GPs are adequately trained to treat skin cancer.

"General practitioners are trained in the management of skin cancers and we manage most skin cancers in the community. In Queensland in particular, GPs are highly experienced at treating skin cancer just because it is so common. General practice is a speciality and Australian and international experience shows that if you look at melanoma in particular, it is identified at a far earlier stage in areas that have a good supply of family GPs," Mitchell says.

But if this seems to be panning out as some sort of turf war, some voices even within the GP "camp" concede some of the criticisms are valid. David Wilkinson, deputy head of the University of Queensland's school of medicine, says GPs working in skin cancer clinics should be required to undergo specialist training. Wilkinson, who is himself a GP and works in a skin cancer clinic one day a week, has called for national standards to be introduced to ensure all clinics offer a high standard of treatment.

'We all agree that some of these clinics provide very high quality care – and some of them clearly do not, and there is a need to address that," he says. "I think there is a desperate need for training."

The University of Queensland will next year introduce a one-year master's degree in skin care medicine for GPs.

"It's the only one I'm aware of in the world and it's an attempt to improve the standards and quality of care for patients. Whether the government or accreditation agencies want to make it a requirement is their business. If you are a doctor with a special interest in skin cancer you should have special skills and that equates to extra training."

The Cancer Council of Australia has also called for skin cancer clinics to be regulated.

It claims that currently, there is no way consumers can be sure they will be treated by doctors experienced in skin cancer treatment. The chairman of the council's national skin cancer committee, Craig Sinclair, says he is concerned that many consumers will think skin cancer clinics are run by experienced cancer specialists.

"There's a perception that doctors at the clinics are well trained and that, in part, is driving the growth in skin clinics usage.

"By far the majority are run by GPs who in some cases may have not have done a great degree of training to be more qualified than the GP at a normal family practice," Sinclair says. "It would be appropriate for GPs that are working at or running these clinics to be more highly trained. Many of them probably become better at detecting skin cancers because they see more of them, but that by itself doesn't necessarily mean that they are always better at treating them."

Sinclair says the lack of regulation governing the clinics is a very real concern.

The council's website lists a series of questions that all consumers should ask clinic staff before they make an appointment.

However, Sinclair believes patients should go to their local GP rather than a skin clinic.

"Our recommendation is that if people are concerned about a lesion that is changing in shape, colour or size they should go to their family doctor who has their medical records and family history, and if there are any concerns they should be referred to a highly trained specialist, which is a dermatologist."

GP Chris Mitchell agrees there is no guarantee that all clinics are staffed by doctors experienced in treating skin cancer.

"It's true that in some skin cancer clinics there isn't a lot of ongoing education but in other clinics there is a lot of ongoing education. I think it is important when patients visit the skin cancer clinics that they aware of the qualifications that the doctor working in the clinic has.

"It is critical for patients to find out what sort of ongoing professional development doctors at clinics have, and the only way you are going to find out is by asking."

John Kelly says that at the very least clinics should not be allowed to advertise they offer specialist services, or that they have computer technology that can diagnose melanomas.

Last year the Australasian College of Dermatologists warned some clinics were making "dangerously misleading and exaggerated" claims about the machines' capacity to detect melanoma.



"Computers are unable to assess the 5 to 10 per cent of melanomas that have no pigment, as well as a further 10 to 15 per cent of melanomas that are of nodular growth pattern," Kelly says. "The machines record images of moles and record their appearance so that change can be detected.

"It's a good way to monitor change in moles but the ability of the doctors to use the image is important. It depends entirely on the doctor's training and expertise, so the machine itself isn't able to diagnose."

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