DS05 Future guidelines should consider time needed to treat in clinics

Abstract

Abstract The British Association of Dermatologists (BAD) published comprehensive guidelines on the management of cutaneous squamous cell carcinomas (cSCC) in 2021, outlining 46 recommendations over 32 pages. These recommendations include a full skin check or total body skin exam (TBSE) for the detection of new malignancies in this at-risk group. We present our experience in implementing this new guidance and the importance of considering the estimated clinician time needed to improve the outcome for one person in the target population (i.e. TNTNNT) when formulating new guidelines (Johansson M, Guyatt G, Montori V. Guidelines should consider clinicians’ time needed to treat. BMJ 2023; 380:e072953). A prospective audit of a skin cancer clinic found that the average consultation time for a patient with a newly diagnosed cSCC was 31 min (range 22–60 min). Follow-up appointments are routinely scheduled at 15 min; therefore, on average, a further 16 min is required to implement the new guidelines for each patient correctly. Recent evidence shows that one new SCC can be diagnosed per 57 TBSEs performed (Harding T, Seyffert J, Maner B et al. Exploring the clinical efficacy of the TBSE. J Clin Oncol 2020. DOI: 10.1200/JCO.2020.38.15_suppl.10078). Therefore, the approximate TNTNNT is 912 min (16 min × 57) or 15.2 h of clinical examination to detect one extra cSCC. This equates to nearly four consultant clinics (one clinic represents 4 h of activity) to detect an additional SCC in a patient group that is already attending for frequent review. There is a paucity of evidence to support the hypothesis that screening and removal of these lesions leads to reduced morbidity and mortality as compared with routine presentation and subsequent management. This lack of evidence is reflected in the US Preventive Services Task Force guidance on TBSE for skin cancer screening, where they provide ‘no recommendation’. Implementing the BAD guidelines has an effect on clinic times and generates an increased surgical caseload. We recommend that future guideline committees should indicate how much extra time in clinic would be required per patient to implement their advice adequately. The TNTNNT is one method to consider the clinical impact of such guidance.