Abstract
Simple SummarySkin cancer is a significant cause of death and disability, particularly in New Zealand. Expert diagnosis reduces unnecessary excision of benign lesions, reduces patient anxiety, and allows early identification of skin cancer, particularly of melanoma. The study assessed an electronic referral pathway for teledermatology—diagnosing skin lesions remotely using a standardised template with regional, close-up, and dermoscopic images—and compared this to scheduled nurse-led teledermoscopy clinics. A dermatology opinion was reached more rapidly with comparable efficacy when referrals include good quality images, compared to nurse-led imaging clinics.We undertook a retrospective comparison of two teledermatology pathways that provide diagnostic and management advice for suspected skin cancers, to evaluate the time from referral to diagnosis and its concordance with histology. Primary Care doctors could refer patients to either the Virtual Lesion Clinic (VLC), a nurse-led community teledermoscopy clinic or, more recently, to the Suspected Skin Cancer (SSC) pathway, which requires them to attach regional, close-up, and dermoscopic images. The primary objective of this study was to determine the comparative time course between the SSC pathway and VLC. Secondary objectives included comparative diagnostic concordance, skin lesion classification, and evaluation of missed skin lesions during subsequent follow-up. VLC referrals from July to December 2016 and 2020 were compared to SSC referrals from July to December 2020. 408 patients with 682 lesions in the VLC cohort were compared with 480 patients with 548 lesions from the 2020 SSC cohort, matched for age, sex, and ethnicity, including histology where available. Median time (SD) from referral to receipt of teledermatology advice was four (2.8) days and 50 (43.0) days for the SSC and VLC cohorts, respectively (p < 0.001). Diagnostic concordance between teledermatologist and histopathologist for benign versus malignant lesions was 70% for 114 lesions in the SSC cohort, comparable to the VLC cohort (71% of 122 lesions). Referrals from primary care, where skin lesions were imaged with variable devices and quality resulted in faster specialist advice with similar diagnostic performance compared to high-quality imaging at nurse-led specialist dermoscopy clinics.
Highlights
Skin cancer prevalence is increasing in association with an ageing population with sun-damaged skin [1]
The incidence of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) is harder to evaluate, given that these are not required to be reported to the cancer registry; research has estimated the incidence of cutaneous SCC to be 425–668 per 100,000 and BCC to be 1177 per 10,000, putting it among the highest in the world [6,7]
Between 1 July and 31 December 2016, 481 patients were referred to the Virtual Lesion Clinic (VLC), of whom 400 patients with 682 lesions were eligible for analysis
Summary
Skin cancer prevalence is increasing in association with an ageing population with sun-damaged skin [1]. New Zealand has one of the highest rates of melanoma in the world, due to high ultraviolet intensities in the Southern Hemisphere during summer and high proportion of the population with fair skin [2,3]. It has an age-standardised incidence of 30–50 per 100,000 [4,5]. In 2016 and 2020 respectively, the Waikato District Health Board, a tertiary dermatology referral centre, had 2.5 and 2.0 full-time equivalent dermatologists for a population of about half a million people [9]
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