Skin Cancer Referrals Research Articles

BT32 Teledermatology service evaluation compared with standard face-to-face review for 2-week-wait skin cancer referrals

BT32 Teledermatology service evaluation compared with standard face-to-face review for 2-week-wait skin cancer referrals

P024 Skin cancer referrals by nonmedical practitioners: a prospective observational study

P024 Skin cancer referrals by nonmedical practitioners: a prospective observational study

BT03 A picture paints a thousand words: simple solutions for optimizing the flow of urgent skin cancer referrals

BT03 A picture paints a thousand words: simple solutions for optimizing the flow of urgent skin cancer referrals

Patient-led skin cancer teledermatology without dermoscopy during the COVID-19 pandemic: important lessons for the development of future patient-facing teledermatology and artificial intelligence-assisted -self-diagnosis.

MySkinSelfie is a mobile phone application for skin self-monitoring, enabling secure sharing of patient-captured images with healthcare providers. This retrospective study assessed MySkinSelfie's role in remote skin cancer assessment at two centres for urgent (melanoma and squamous cell carcinoma) and nonurgent skin cancer referrals, investigating the feasibility of using patient-captured images without dermoscopy for remote diagnosis. The total number of lesions using MySkinSelfie was 814, with a mean patient age of 63 years. Remote consultations reduced face-to-face appointments by 90% for basal cell carcinoma and by 63% for referrals on a 2-week waiting list. Diagnostic concordance (consultant vs. histological diagnosis) rates of 72% and 83% were observed for basal cell carcinoma (n = 107) and urgent skin cancers (n = 704), respectively. Challenges included image quality, workflow integration and lack of dermoscopy. Higher sensitivities were observed in recent artificial intelligence algorithms employing dermoscopy. While patient-captured images proved useful during the COVID-19 pandemic, further research is needed to explore the feasibility of widespread patient-led dermoscopy to enable direct patient-to-artificial intelligence diagnostic assessment.

Skin cancer referrals by nonmedical practitioners: aprospective observational study.

The aim of this study was to investigate the appropriateness of suspected skin cancer referrals made by nonmedical practitioners (NMPs) and compare this with referrals made by local general practitioners (GPs). Data were collected prospectively from patients referred from primary care to a UK hospital dermatology department. The profession of the referrer was ascertained from review of referral letters and direct questioning. Patient records and subsequent histology reports were reviewed to determine the ultimate diagnoses. Eighty-nine per cent of patients (n = 668/753) were referred by GPs vs. 11.3% (n = 85/753) by NMPs. Fifty-one per cent of patients (n = 340/668) in the GP group and 55% (n = 47/85) in the NMP group were discharged without intervention (P = 0.45). An ultimate diagnosis of skin malignancy was made in 196 of 668 (29.3%) patients in the GP and 25 of 85 (29%) patients in the NMP group (P = 0.99). These early data suggest significant potential for NMPs to become more involved in skin lesion assessment.

Comparing the number-needed-to-biopsy ratio for melanoma diagnosis between teledermatology and face-to-face models ofcare.

The UK elective recovery plan has advocated that teledermatology (TD) should be available in every service receiving urgent suspected skin cancer referrals. Currently, TD plays an important role in some NHS dermatology services in triaging referrals on the skin cancer 2-week-wait (2WW) pathway, given the necessity for rapid lesion assessment and the ever-increasing volume of 2WW referrals received. However, evidence supporting the effectiveness of TD for the accurate diagnosis and triage of skin lesions remains insufficient, with further prospective and pragmatic evaluation required.

009 Comparing the number needed to biopsy (NNB) ratio for melanoma diagnosis between teledermatology and face-to-face models of care

Abstract The Elective Recovery Plan, published by NHS England (2022), has advocated that teledermatology (TD) should be available in every service receiving urgent suspected skin cancer referrals. However, evidence supporting the effectiveness of TD for the accurate diagnosis and triage of skin lesions remains limited. A 2018 Cochrane review found variable agreement between TD and face-to-face (FTF) assessment of lesions considered to be of low concern when seen FTF, with remote assessment more likely to recommend intervention (including excision) for low-risk lesions. The number needed to biopsy (NNB) ratio, calculated by dividing the total number of biopsies by the number of biopsied skin cancers, is increasingly used as a metric for the diagnostic accuracy for melanoma detection, with a low ratio suggesting high specificity and vice versa. We undertook a study to compare the NNB ratio for melanoma detection between TD and FTF models for assessing new 2-week-wait (2WW) skin cancer referrals within our service. Over 2019–2020, the service switched over from FTF to a full TD consultant-run model for 2WW referrals. Retrospective analysis of the FTF 2WW model between August and November 2018 identified 53 cases suspicious for melanoma referred for biopsy [30 women and 23 men; median age 44 years (range 27–90)]. Of these, six patients received a histopathological diagnosis of melanoma (NNB 8.8). Retrospective analysis of the TD model between August and November 2022 identified 62 cases suspicious for melanoma triaged directly to a biopsy appointment [37 women and 25 men; median age 49.5 years (range 18–90)]. Of these, three patients received a histopathological diagnosis of melanoma (NNB 20.7). NNB in the TD model was 2.3 times higher than in the FTF model. The NNB of 8.8 in our FTF 2WW model is comparable to a review of 46 studies, which generated an NNB of 7.5 for dermatologists worldwide. The higher NNB of 20.7 for TD indicates poorer diagnostic accuracy for melanoma in this model. The higher NNB in TD is consistent with previous findings that remote assessment is more likely to lead to the excision of low-risk lesions. Further large-scale studies are needed to compare NNB in teledermatology vs. FTF models of skin cancer assessment. TD brings considerable advantages of convenience and increased clinic capacity but may come at a cost of lower specificity for melanoma diagnosis and an increase in the number of biopsies of benign lesions.

BT17 Patient Assessment Wrap-up Session: the utility of consensus decision-making in teledermatology

Abstract In our unit, skin cancer referrals are triaged via teledermatology following high-quality image capture of lesions, including dermoscopic views. Patients are discharged, invited for a face-to-face assessment or listed directly for surgery. Remote and asynchronous consultations are at odds with the traditional clinical training all our consultants underwent, and therefore introduce new uncertainty into our work. As a way to maximize remote discharges, and improve the consistency of and the confidence in our own teledermatology diagnoses, we developed Patient Assessment Wrap-up Session (PAWS). This is an email-based discussion group allowing consensus decision-making on cases with lesions that demonstrate some ambiguity and that individually we would usually bring to a face-to-face appointment. Between March and April 2022, a total of 566 teledermatology cases were allocated to five consultants within the department. In total, 476 (84.1%) were dealt with independently by the allocated consultant. The remaining 90 cases (15.9%) were discussed via PAWS, with 48 (53%) being discharged as a result. On average, four clinicians responded to the PAWS request, and the average time to reach a consensus was 14 h. Of those discharged, two were re-referred within 6 months, one for different lesions and one for the same noncancerous lesion; however, both were discharged again. The additional discharges led to 16 h of clinic time saved, but the PAWS time cost between 12 and 18 h. Although PAWS is currently probably consultant-time neutral, the timing is more flexible than a face-to-face clinic. Additional advantages have also become apparent while using the process. It aids continued professional development and peer assessment while simultaneously providing a service. The patients discharged after PAWS are also saved from a fossil fuel burning visit to the hospital and having to take time off work, and so on. The PAWS also allows for junior colleagues to leverage support from more experienced clinicians when balancing risk and dealing with difficult decision-making. We would like to share our PAWS process as it may also benefit other services using teledermatology.

BT06 Using artificial intelligence to triage skin cancer referrals: outcomes from a pilot study

Abstract Artificial intelligence (AI) is a rapidly emerging field in dermatology, aimed at delivering efficient and effective patient care. To date, there is a lack of substantial evidence for the use of this technology in a clinical setting. However, the pandemic era has placed significant pressures on dermatology services, specifically the skin cancer clinics at our trust, which has experienced a 30% increase in demand compared with prepandemic levels. A novel solution for urgent referrals was to test the use of AI teledermatology software using a UK Conformity Assessed marked Class IIa Medical Device (and therefore regulated by the Medicines and Healthcare products Regulatory Agency). Appropriate cases are selected and booked for a teledermatology appointment at one of our four community-based hubs. Clinical and dermoscopic images, together with a short questionnaire, are uploaded to the software by a healthcare assistant. The AI immediately assesses the dermoscopic images of the lesion, and those cases identified as benign are discharged back to the general practitioner (GP), following a safety check by a consultant dermatologist employed by the AI provider. The trust dermatology consultants have chosen to further triage all cases suspected to be nonbenign. Patients with suitable small lesions at low-risk sites receive a telephone appointment to discuss surgery and obtain consent. Those with precancerous lesions can be discharged back to the GP with management advice. Low-risk basal cell carcinomas case are transferred to a routine pathway. Selected cases may be referred directly to other teams. The pilot started in March 2022 and now processes 5–600 cases per month at four photography hubs. To date, 19% of cases have been discharged back to the GP with a benign diagnosis. A further 15% of cases have been discharged back to the GP by the trust dermatologists, giving an overall discharge rate of 34%. Ten per cent of patients have received a telephone call to take consent for biopsy, and 2% have been referred directly to another speciality. Thirteen per cent of cases have been triaged to a routine pathway, and 38% of patients have required an urgent face-to-face appointment with a dermatologist. The trust has seen > 90% 2-week wait referrals within 2 weeks in the last two quarters. Since the introduction of this AI teledermatology service, we have seen a 62% reduction in the number of patients requiring an urgent face-to-face appointment with a dermatologist. Ongoing audit work is focused on the safety, acceptability and cost-effectiveness of this pathway, and will shape decision-making in the ongoing use of this technology both locally and across the UK.

BT05 Community and Locality Imaging Centres: innovation in the skin cancer care pathway

Abstract Timely management of patients referred with suspected skin cancer remains challenging due to demand that exceeds the capacity of dermatology departments. Encouraging the attachment of images and key metadata along with referrals from primary care helps promote enhanced clinical referral triage. We describe the process of establishing Community and Locality Imaging Centres (CLICs) that seek not only to promote efficient triage, but also to establish a national pipeline of anonymized images, with linked Digital Imaging and Communications in Medicine (DICOM®) data, to assess the potential for future use of artificial intelligence (AI) algorithms in clinical practice. General practitioners (GPs) can request a CLIC appointment at the time of referral, removing the time pressure and potential technical barriers associated with photography and image attachment. Each centre follows the same standardized image capture and hardware operating procedure, ensuring that high-quality, in-focus digital images are consistently acquired. The CLIC appointments take an average of 15 min, during which a suitably trained healthcare professional obtains written patient consent and, using a National Health Service-approved mobile phone with a dermatoscope attachment, takes paired macroscopic and dermoscopic views of each lesion. Relevant metadata, in line with the recently agreed DICOM standards for dermatology, are recorded for individual lesions, enhancing the utility of each photograph. Paired images and metadata are regularly archived to a secure medical image management system and are linked with the referral, allowing dermatologists to perform enhanced clinical triage and communicate one of the following outcomes directly to the referring GP: routine dermatology appointment, urgent dermatology appointment, direct to biopsy or benign lesion–reassurance and discharge. This process aims to streamline the primary care referral pathway and promote immediate benefits to patient care by reducing unnecessary travel for face-to-face outpatient appointments. The establishment of CLICs in Scotland supports referral optimization by providing an efficient, convenient option for GPs and patients to obtain high-quality clinical photography. This model allows for flexible integration into local services: hospital-based with medical photographers, intermediate secondary care-led centres or community-based primary care hubs. Suspected skin cancer referrals can be efficiently triaged by dermatologists when paired with macroscopic and dermoscopic images and relevant patient metadata compliant with DICOM standards. The same images and metadata, once anonymized, can be securely transferred to a nationwide database for deep learning AI algorithm development. Validated AI programs, with the aim of being deployed at the primary care level, inform opportunities for further enhancement of the referral pathway.

BT23 Outcomes of skin lesion referrals assessed via teledermoscopy

Abstract Skin lesion referrals from primary care comprise a significant proportion of the dermatology workload. Urgent suspected cancer (USC) referrals are prioritized, which adds strain to outpatient capacity and impacts on waiting lists for less urgent and routine referrals. Our department provides a teledermoscopy diagnostic service to allow for timely diagnosis of skin lesions. This results in fast detection of USC and a reduction in unnecessary hospital visits for patients with benign lesions. The aim of this study was to review the outcomes of USC and routine referrals received from primary care and assessed via our teledermoscopy service. We randomly selected 381 skin lesion referrals triaged for teledermoscopy between January and March 2022. In total, 189 (49.6%) of these were referred as routine and 192 (50.4%) were urgent/USC. High-resolution clinical and dermoscopic photographs of all skin lesions were taken by qualified clinical photographers and stored in the patients’ electronic records. Two separate consultant dermatologists reviewed the images along with the information provided in the referrals for diagnosis. A total of 47 diagnoses were observed in both cohorts. Only 16% of patients referred as urgent/USC had suspected high-risk cancer, including squamous cell carcinoma (SCC; 8.8%), melanoma (5.7%) and lentigo maligna (1.5%). The remainder of urgent/USC referrals were identified as nonurgent or benign, with an overwhelmingly low risk of basal cell carcinoma (23.9%), seborrhoeic keratoses (20.8%) and benign naevi (9.3%). For routine referrals, 11 patients (5.8%) were suspected to have USC. Of these, five had histological confirmation of melanoma (n = 3), SCC (n = 1) and melanoma in situ (n = 1). Of all referrals, 44.6% were reassured and discharged; 20.8% required clinic review for a diagnostic biopsy or treatment; 20.7% were booked directly for minor surgery; 8.3% were referred to the community local enhanced services for the treatment of low-risk lesions on the torso and limbs; 1.3% were referred to other specialties; and 4.1% required digital monitoring by repeating photographs 3–6 months later. An ever-increasing prevalence of skin cancer, together with suboptimal dermatology training for primary care healthcare professionals, anxiety over misdiagnosing malignancy and pressure from anxious patients all contribute to the pressure on dermatology services. We have shown that a teledermoscopy service is a useful tool for triaging skin cancer referrals to maximize the utilization of outpatient capacity and ensure timely treatment for patients with USCs.

BT09 Clinical performance of an artificial intelligence-based medical device deployed within an urgent suspected skin cancer pathway

Abstract A secondary care trust received over 2800 urgent suspected skin cancer referrals (USCRs) in 2021, 50% more than in 2016 (www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times), < 1 in 10 of which resulted in diagnosis of skin cancer (www.cancerdata.nhs.uk/cwt_conversion_and_detection). Judicious implementation of artificial intelligence (AI) may improve referral accuracy. We conducted a prospective, postdeployment, single-centre clinical performance review of a UK Conformity Assessed Class IIa-approved, AI-based, skin lesion analysis medical device intended for use in the screening, triage and assessment of skin lesions suspicious for skin cancer (AIaMD). The AIaMD is deployed at the trust as a decision-support tool following USCR from primary care, with a second read of all cases by a consultant dermatologist. Patients assessed by the two most recent versions of AIaMD from October 2021 to October 2022 were eligible for inclusion. Outcomes were confirmed from histology reports for cancerous lesions and histology reports or Consultant teledermatology assessment for noncancerous lesions. The AIaMD assessed 1363 lesions with outcomes confirmed, including 51 melanomas, 64 squamous cell carcinomas (SCCs), 96 basal cell carcinomas, 8 rare skin cancers and 244 premalignancies. The AIaMD referral sensitivity for melanoma, all skin cancer and premalignancy was 100% (n = 51/51), 99.5% (n = 218/219) and 96.3% (n = 235/244), respectively. The AIaMD benign lesion specificity was 55.9% (n = 434/777). The negative predictive value (how often AIaMD labelled lesions as premalignant/benign and correctly ruled out cancer) was 99.8% (n = 539/540). The conversion rate (the percentage of lesions classified as high risk by AIaMD that resulted in a diagnosis of melanoma or SCC) was 13.8% (n = 122/886), while the USCR conversion in the local clinical commissioning group was 9.9% in 2020–2021. The service discharged 9.4% (n = 239/2551) of patients during this time without using trust dermatologist capacity, with the potential to have discharged 18.3% (n = 467/2551) without a second read. This postmarket service evaluation reported the clinical outcomes of an AI device used for assessment of skin lesions. The pathway was sensitive, identifying 218 of 219 skin cancers, and specific, correctly identifying over half of benign lesions. Moreover, AIaMD was able to improve the conversion rate of USCRs. The integration of AIaMD into skin cancer diagnostic pathways could significantly improve the accuracy of USCRs. Conflicts of interest: these were commercial deployments of the AI, and three of the authors are employed by the AI provider.

Patient-captured images in the triage of skin lesions: 'Project Skin Selfie'.

Dermatology services are overwhelmed with 2-week wait (2WW) skin cancer referrals. We outline a triage system using patient-captured images, taken by dermoscopic smartphone attachments.

PA16: Two‐week wait skin cancer referrals to a paediatric dermatology clinic: a service evaluation

PA16: Two‐week wait skin cancer referrals to a paediatric dermatology clinic: a service evaluation

Are We Missing Something? The Skin Lesions Not Seen in Teledermatology

Background The suspected skin cancer electronic referral pathway was introduced in 2017. It requires general practitioners to add regional, close-up, and dermoscopic images to a lesion-specific referral template for a teledermatologist to review and advise on management. The virtual lesion clinic is a nurse-led clinic used since 2010 to obtain high-quality images for teledermoscopy assessment. A limitation of both services is the absence of a full-body examination. Objective This study aims to evaluate the number of skin cancers missed during teledermatology assessment. Methods This is a retrospective review of skin lesion referrals to dermatology. Suspected skin cancer referrals made in the latter half of 2020 were compared with referrals to the virtual lesion clinic during a similar time period in 2016. Results The study included 481 patients with 548 lesions in the 2020 suspected skin cancer cohort that were matched for age, sex, and ethnicity to 400 patients with 682 lesions in the 2016 virtual lesion clinic cohort. A total of 41 patients underwent subsequent specialist review in the suspected skin cancer cohort compared to 91 in the virtual lesion clinic cohort. A total of 20% of the suspected skin cancer cohort and 24% of the virtual lesion clinic cohort were found to have at least one additional lesion of concern. The majority of these were keratinocytic skin cancers; there were 2 and 0 additional melanomas or melanoma-in-situ, respectively. The virtual lesion clinic nurses identified additional lesions for imaging in 78 of 400 (20%) patients assessed in the virtual lesion clinic. The teledermatologist determined (author AO) that 73% of these additional lesions were malignant. Of the 548 lesions, 10 (2%) in the suspected skin cancer group were rereferred, none of which had a change in diagnosis. Out of 682 lesions, 16 (2%) in the virtual lesion clinic cohort were rereferred, 6 (1%) of which had a change in diagnosis. Conclusions Patients diagnosed with skin cancer often have multiple lesions of concern. Single-lesion teledermoscopy diagnoses have high concordance with in-person evaluation and histology; however, we have shown that in-person examination may reveal other suspicious lesions. The importance of a full-body skin examination should be emphasized to the referrer. Acknowledgments The Waikato Medical Research Foundation provided financial support for the study. Conflicts of Interest None declared.

A summary of the updated report on the incidence and epidemiological trends of keratinocyte cancers in the UK 2013–2018

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.1, 2 The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

P54: Potential impact of remote consultations in primary care on teledermatology and 2‐week wait (2WW) suspected skin cancer referrals: the need for a range of innovative approaches for pre‐2WW triage

P54: Potential impact of remote consultations in primary care on teledermatology and 2‐week wait (2WW) suspected skin cancer referrals: the need for a range of innovative approaches for pre‐2WW triage

Identification of Incidental Skin Cancers Among Adults Referred to Dermatologists for Suspicious Skin Lesions

The incidence of skin cancer is increasing and evaluation of the utility of total body skin examination (TBSE) in detecting incidental skin cancers is warranted. To evaluate the proportion and rate of incidental skin cancer detection in urgent skin cancer clinics and investigate the rate of incidental skin cancer detection in 2 groups based on the degree of clinical suspicion of the index lesion for malignancy. A multicenter retrospective cohort study with a case note review of consecutive secondary care consultations was conducted using data from 2 urgent suspected skin cancer screening clinics in UK National Health Service trusts. The study was performed from January 1, 2015, to March 31, 2016, and data analysis was performed from October 14, 2018, to February 1, 2019. Patients included those presenting with a skin lesion suspicious of malignancy who were referred to the urgent suspected skin cancer clinic (N = 5944) over 15 months. Patients who accepted and received a TBSE were subsequently included in the analysis. The proportion and rate of incidental skin cancer detection through TBSE and whether a clinically suspicious (malignant) index lesion was associated with a higher chance of having a malignant incidental lesion. Of the 5944 patients referred to the clinic, 4726 individuals (79.5%) were evaluated. In the cohort included in the analyses, the median age was 57 years (interquartile range, 39-73 years); 2567 patients (54.3%) were women. A total of 1117 skin cancers were identified; of these, 242 lesions (21.7%) were detected incidentally through TBSE, including 197 of 570 (34.6%) basal cell carcinomas, 16 of 250 (6.4%) squamous cell carcinomas, and 25 of 215 (11.6%) melanomas. The detection rate of incidental malignant lesions was 5.1 lesions per 100 patients examined (5.1%; 95% CI, 4.5%-5.8%). There was a higher detection rate of histologically confirmed incidental malignant lesions in individuals with clinically suspicious index lesions requiring biopsy (10.9%; 95% CI, 9.5%-12.5%) compared with those presenting with clinically benign index lesions (2.0%; 95% CI, 1.6%-2.5%) (P < .001). The findings of this study support the use of TBSE for urgent skin cancer referrals, highlighting the potential harms of solitary lesion assessment in a subgroup. Individuals presenting with a clinically suspicious index lesion requiring biopsy are most likely to benefit from TBSE and should be counseled regarding the benefit.

Patient satisfaction with a new skin cancer teledermatology service.

Rising numbers of two-week-wait (2WW) skin cancer referrals have caused increasing pressure on UK dermatology departments. Initiatives to address this include teledermatology. Previous studies have indicated good patient acceptability but most have focused on general dermatology rather than skin cancer referrals, and have taken place in rural settings, where teledermatology may be preferable. To evaluate patient satisfaction of teledermatology 2WW services in a London-based tertiary National Health Service (NHS) setting. A literature search was performed and a patient satisfaction survey was designed to evaluate: (i) ease of completing a questionnaire about the skin lesion; (ii) lifestyle impact; (iii) preferences regarding electronic data collection and communication of results; and (iv) confidence in the service. A five-point Likert scale was used to assess responses. The study took place over a 20-week period. Over half (51%; n=31 of 60 patients) were female; 78% (47) were aged ≤55years and 65% (39) were Caucasian. Over 80% (49) would recommend the service, and the majority felt confident with the teledermatology model. Overall, patients would be happy to complete electronic questionnaires and receive results electronically, with younger patients being more amenable to this. Patients with better health status, those of younger age and those with less frequent visits to a dermatologist were more accepting of teledermatology. To our knowledge, this is the first comprehensive study evaluating patient satisfaction with teledermatology specifically for 2WW referrals in an NHS setting. As skin cancer referrals increase, dermatology departments must adjust. Patient involvement and feedback is paramount in implementing and expanding teledermatology services.

Pilot Teledermatology Service for Assessing Solitary Skin Lesions in a Tertiary London Dermatology Center.

Efficient clinical pathways are needed to meet the growing pressures in dermatology due to the significant rise in the number of suspected skin cancer referrals. Our hospital serves a wide geographical area and receives a large number of 2-week-wait (2WW) suspected skin cancer referrals. In the United Kingdom, approximately 10-12% of 2WW referrals are diagnosed as skin cancers fulfilling the 2WW criteria. We sought to assess the role of teledermatology in reducing hospital consultations for patients referred via the dermatology 2WW pathway. We piloted a teledermatology service and detailed the clinical outcomes of patients with solitary skin lesions of uncertain diagnosis triaged through this pathway. Seventy-six primary care referrals were reviewed by consultant dermatologists and analyzed against the British Association of Dermatologists' teledermatology audit standards. In 52/76 (68%) of patients, confident benign diagnoses were made, avoiding the need for a face-to-face (FTF) consultation. Our results showed that with adequate image quality, teledermatology can be used to accurately diagnose skin lesions. Teledermatology can significantly reduce the number of urgent referrals necessitating FTF appointments, therefore providing a new solution to streamline care delivery.