This week brings the start of meteorological summer and the twin temptations of sunny skies and warmer temperatures invite us to indulge in lazy days on the beach, picnics in the park and barbeques in our gardens.  However, the advent of better weather brings with it increasing UV exposure, which is the main preventable cause of skin cancer.

The British Skin Foundation tells us that skin cancer is the most common form of cancer in the UK and rates, particularly of malignant melanoma, the most dangerous form of skin cancer, continue to rise.  Their data shows that at least 100,000 new cases of skin cancer are diagnosed each year and over 2,500 people die from the disease each year.

What to look out for - ABCD

Malignant melanoma may present as a new lesion or as changes in an existing mole and the key factors to look for are:

  1. – asymmetry 
  2. – irregular border
  3. – different colours within the lesion
  4. – increasing diameter

Any one of the above or any other change in a mole or new lesion should be considered suspicious and medical advice sought.

NICE guidelines

The NICE guidelines for health professionals mandate that any patient with a lesion suspected to be a melanoma should receive an urgent referral to a dermatologist or other suitable specialist and excision in primary care should be avoided.

The reason that malignant melanoma is so dangerous is that if it is not identified and treated early, it spreads deep into the tissues and can also spread to the organs.  Malignant melanoma can kill and therefore the utmost vigilance is needed by patients and by doctors, as early diagnosis is both possible and makes a real difference. 

For advanced melanoma sufferers, there is recent good news in that immune therapy may be an effective treatment for some.  The BBC reports that an international trial on 945 patients found treatment with ipilimumab and nivolumab shrunk tumours or stopped the cancer advancing for nearly a year in 58% of cases.

Legal issues

However, far preferable is that melanoma never reaches this stage in the first place.  The BBC story reporting the trial data references the case of a patient involved in the trial, who had a lesion on her face classified as benign which then spread to her lungs.  In my medico legal practice, I have dealt with a similar case of a changing mole having been biopsied and reported as benign which later transpired to be a melanoma; sadly that patient also went on to develop metastases with devastating effects for the patient and his family.

I also have personal experience of melanoma having not been appropriately recognised.  I identified a suspicious mole in a family member based on the ABCD criteria above.  The GP thought that the mole was nothing to worry about and put my family member on the list for excision at the GP practice.  Several months later, when the mole continued to change and look even more sinister, he re-attended and I accompanied him.  Even with me pointing out how the mole had changed with reference to the ABCD criteria, the GP, this time a partner in the practice, seemed unconcerned but he chased up the appointment for the mole to be removed, which took place about a month later.  The mole was sent off for routine testing and it transpired that what two GPs had thought was nothing to worry about was in fact a low grade melanoma.  A wider excision was necessary to ensure that a clear margin was taken.  Happily, despite the delay, the melanoma was still at an early stage but had my family member been referred to a dermatologist when he first presented, as he ought to have been, one of the excision procedures could have been avoided. 

In my opinion, there is simply no excuse for not referring anyone with a suspicious skin lesion to a dermatologist.  Dermatologists have the appropriate training and equipment to reach a decision as to whether a lesion warrants removal or not and, for the most part, GPs do not have the training or equipment to come to a similarly informed decision.  Likewise, the histological reporting of lesions should be always be accurate so that appropriate treatment can be provided.  However, sadly negligent mistakes do occur, both in terms of referring appropriately and reporting of histology, and such mistakes can turn out to be life altering or life limiting for the patient.

My advice is to be vigilant about checking your own skin and that of your family members. For men the most common site for a melanoma is the torso and for women it is the legs; it is difficult to carefully examine your own back or the backs of your legs, so get help to check these parts of your body.  If you do notice a new lesion or a changing mole, see your GP immediately and do not be afraid to press for a referral to a dermatologist.  It is far better to be safe than sorry.

Prevention is better than cure

Finally, as advised by the British Skin Foundation, UV exposure is the single biggest preventable cause of melanoma so, when enjoying the sunshine, do so safely; cover up with appropriate clothing, apply sunscreen before you go out and reapply frequently, wear a hat and sunglasses and avoid sun exposure in the hottest parts of the day.  One final plea, all of the above are even more important for children, as one episode of severe sunburn in childhood is thought to be enough to double the lifetime risk of skin cancer.