1. Purpose
A dermatology service sees skin lesions every day, and a missed melanoma or squamous cell carcinoma can cost a life. This policy sets out how the Service recognises lesions that may be cancer, refers them urgently down the right pathway, and makes sure no patient with a worrying lesion is lost to follow-up.
The Service must verify this policy against current NICE suspected-cancer referral guidance and British Association of Dermatologists guidance before adoption.
2. Sources to verify before adoption
- NICE NG12, Suspected cancer: recognition and referral: https://www.nice.org.uk/guidance/ng12
- NICE NG14, Melanoma: assessment and management: https://www.nice.org.uk/guidance/ng14
- British Association of Dermatologists, clinical guidelines: https://www.bad.org.uk/
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
3. Scope
This policy applies to:
- the assessment of any skin lesion the Service sees
- the referral of lesions that may be cancer, and the follow-up of those referrals
- the clinicians who assess lesions and the staff who manage referrals and results
4. Recognising a lesion that may be cancer
Clinicians assess lesions against current criteria, including:
- a pigmented lesion that is changing, asymmetrical, has an irregular border or colour, is growing, or scores on a recognised checklist
- a non-healing, ulcerated, crusting or bleeding lesion
- a new or enlarging lesion in an at-risk patient (sun exposure history, previous skin cancer, immunosuppression, fair skin)
- a patient's own concern about a changing mole, which is taken seriously even when the lesion looks reassuring
The clinician uses dermoscopy where competent (see the dermoscopy and lesion documentation policy) and documents the assessment.
5. Urgent referral
Where a lesion may be cancer, the Service refers it urgently down the right pathway, within the timescale the guidance sets, and does not delay by watching and waiting where the criteria for referral are met. The referral:
- goes to a service that can diagnose and treat skin cancer
- includes the clinical description, the lesion location, any dermoscopy image, and the patient's risk factors
- is made with the patient's understanding of why and what happens next
Where the Service itself excises a lesion that may be cancer, it follows the minor skin surgery and specimen handling policy, including correct specimen handling and acting on the histology result.
6. Safety-netting the patient
The patient is told, in a form they can keep:
- what has been found and what the referral is for
- what to do if symptoms change while they wait
- that they should chase the appointment if they do not hear, and how to contact the Service
The Service does not rely on the patient alone to drive the pathway.
7. Tracking referrals and results
The Service runs a system so no urgent referral or pending result is lost:
- every urgent referral is logged and tracked until the patient is seen or the result is back
- histology and pathology results are checked, acted on and recorded, with a fail-safe so a result that does not arrive is chased
- a malignant result triggers prompt action and clear communication with the patient
8. When something is missed or delayed
A missed or delayed skin-cancer diagnosis is treated as a serious patient-safety matter. It is logged, investigated, and the duty of candour is opened where the threshold is met. The Service reviews how the lesion or result was missed and changes the system to prevent a repeat.
9. Training
Clinicians who assess skin lesions keep their skin-cancer recognition current, including dermoscopy where they use it, and are refreshed on a stated cadence. The Service records who is competent and the next refresher date.
10. Audit cadence
The Service checks, on a stated cadence, that:
- lesion assessments are documented against current criteria
- urgent referrals are made within the guidance timescale and tracked to the patient being seen
- pathology results are checked, acted on and fail-safed, with none outstanding unnoticed
- missed or delayed diagnoses are investigated and learned from
The Registered Manager and the clinical lead review the results and record the improvement actions that follow.