Patients with skin cancers are receiving poor treatment from family doctors, a series of studies has shown. Up to half of cancers were removed incompletely when the operation was done by GPs.

This means that the cancer is likely to recur and require a second operation. In the case of the deadliest cancer, melanoma, failure to remove it all could mean that the cancer will spread and make it much harder to treat. In the worst case, a patient will die who could have been saved if the initial operation had been performed competently.

The audits are important because the Government’s policy is to encourage more GPs to undertake minor surgery, such as removing skin cancers. The belief is that this will be cheaper than referring patients to consultants, more convenient to patients and no less safe.

“The issue is one of patient safety,” said Dr David Shuttleworth, clinical vice-president of the British Association of Dermatologists. “This is not a trade war. We have no problem with GPs treating skin cancers, so long as they produce results as good as hospital consultants. But these studies show that a significant number are not very competent. GPs say they are fine. But they don’t all collect their evidence, they don’t measure results and they don’t count the times they go wrong. The surveys show they are not good at diagnosis, and that they operate on things they don’t understand.”

At a meeting of the Association of Dermatologists in Liverpool, nine studies were presented that showed failings in operations carried out by GPs. These included the worst results for removal of basal cell carcinomas (BCC): in a countywide study in Cornwall, 54 per cent were removed incompletely, compared with 11 per cent in hospitals.

The quality of skin surgery is measured from samples removed and sent to hospitals, These are sliced up and tissue at the edges of the sample examined for cancer cells. If the cancer has been excised correctly, the cells at the edge of the specimen should be healthy. If they are cancerous, not enough has been removed.

Dr Helena Malhomme dela Roche, who carried out the study, said: “The incomplete excision rates for patients with high-risk BCC managed by GPs is unacceptably high at 54 per cent.”

Dr Elisabeth Fraser-Andrews, one of the authors of a study of BCC surgery in Essex, said: “The proportion of BCCs excised in primary care is low, showing that patients receive sub-optimal treatment in primary care compared with secondary care.

“These findings support recommendations in the guidance from the National Institute for Health and Clinical Excellence (NICE) and the Department of Health and indicate that it is imperative for GPs who wish to carry out surgical treatment of skin cancer in primary care to be adequately trained, audited regularly and accountable to a clinical govenance structure.”

The NICE guidance was published in 2006, and will come into force fully next March. Among other things, it calls for all those carrying out minor surgery to be fully accredited. The GP committee of the British Medical Association has objected to the guidance. Dr Laurence Buckman, chairman of the committee, said: “Other surveys do not show the same results as these, but I’m not going to defend GPs who do it badly.

“The problem with the new guidelines is that they are so tightly drawn that GPs won’t be able to do any surgery at all. GPs weren’t involved in drawing up the guidelines, and they are unworkable. The only people who could qualify are specialists. ”

Flawed treatments

- 31 per cent of skin cancer samples removed by GPs were incomplete, an audit at Derbyshire Royal Infirmary found

- In Sussex, 14 per cent were inappropriately treated by GPs

- A London teaching hospital found that 14 per cent of those operated on by GPs should have been referred directly to hospital

- Three studies looked only at basal cell carcinomas (BCC), the lowest-risk skin cancers. More than a third had been removed incompletely by GPs. In Essex, the figure was 46 per cent

- Worst results for BCC came from Cornwall, where 54 per cent were removed incompletely

- A study in Norfolk of squamous cell carcinomas (SCC) found that patients were not being referred urgently to specialists, partly because GPs were carrying out biopsies themselves. As a result it took 79.5 days, rather than 35.8, for the cancer to be removed

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