Adv Ther (2020) 37:603–616

https://doi.org/10.1007/s12325-019-01130-1

PRACTICAL APPROACH

Recognising Skin Cancer in Primary Care

Owain T. Jones . Charindu K. I. Ranmuthu . Per N. Hall .
Garth Funston . Fiona M. Walter

Received: September 3, 2019 / Published online: November 16, 2019

Ó The Author(s) 2019

ABSTRACT considered preventable. Primary care clinicians

have a vital role to play in detecting and
Skin cancer, including melanoma, basal cell managing patients with skin lesions suspected
carcinoma and cutaneous squamous cell carci- to be skin cancer, as timely diagnosis and
noma, has one of the highest global incidences treatment can improve patient outcomes, par-
of any form of cancer. In 2016 more than ticularly for melanoma. However, detecting
16,000 people were diagnosed with melanoma skin cancer can be challenging, as common
in the UK. Over the last decade the incidence of non-malignant skin lesions such as seborrhoeic
melanoma has increased by 50% in the UK, and keratoses share features with less common skin
about one in ten melanomas are diagnosed at a cancers. Given that more than 80% of skin
late stage. Among the keratinocyte carcinomas cancers are attributed to ultraviolet (UV) expo-
(previously known as non-melanoma skin can- sure, primary care clinicians can also play an
cers), basal cell carcinoma is the most common important role in skin cancer prevention. This
cancer amongst Caucasian populations. The article is one of a series discussing cancer pre-
main risk factor for all skin cancer is exposure to vention and detection in primary care. Here we
ultraviolet radiation—more than 80% are focus on the most common types of skin cancer:
melanoma, squamous cell carcinoma and basal
cell carcinoma. We describe the main risk fac-
tors and prevention advice. We summarise key
Enhanced Digital Features To view enhanced digital guidance on the symptoms and signs of skin
features for this article go to https://doi.org/10.6084/ cancers and their management, including their
m9.figshare.9976475. initial assessment and referral. In addition, we
review emerging technologies and diagnostic
O. T. Jones (&)
G. Funston
F. M. Walter aids which may become available for use in
The Primary Care Unit, Department of Public Health
primary care in the near future, to aid the triage
and Primary Care, University of Cambridge,
Cambridge, UK of suspicious skin lesions.
e-mail: otj24@medschl.cam.ac.uk

C. K. I. Ranmuthu
Clinical School, University of Cambridge, Keywords: Basal cell carcinoma; Early
Cambridge, UK diagnosis; Melanoma; Primary care; Skin
cancer; Squamous cell carcinoma
P. N. Hall
Addenbrookes Hospital NHS Foundation Trust,
Cambridge, UK
604 Adv Ther (2020) 37:603–616

incidences of any form of cancer [1]. Melanoma

Key Summary Points is the fifth most common cancer in the UK,
with around 16,000 patients diagnosed in 2016.
Skin cancer, including melanoma and If melanoma is diagnosed at an early stage,
keratinocyte carcinomas (basal cell 5-year survival can be up to 95%, making early
carcinoma and cutaneous squamous cell detection and treatment key to improving sur-
carcinoma), has one of the highest global vival. However, melanoma is prone to metas-
incidences of any form of cancer. tasise, making it responsible for up to 90% of
Incidence rates of these types of skin skin cancer deaths (2285 deaths in 2016 in the
cancer are increasing. UK) [2, 3]. Furthermore, among Caucasian
populations in the UK, the incidence of mela-
Primary care clinicians have a vital role to noma has quadrupled over the last 30 years, and
play in detecting and managing patients is expected to be among the cancers with the
with skin lesions suspected to be cancer; fastest increasing incidence over the next
timely diagnosis and treatment can 20 years, rising by a further 7% [4].
improve patient outcomes, particularly The ‘non-melanoma skin cancers’ (NMSC)
for melanoma. However, detecting skin include SCC and BCC, although they arise from
cancers can be challenging. keratinocyte cells and are increasingly known as
80% of skin cancers are considered keratinocyte carcinomas (KCs) [5]. They are very
preventable, primarily through reduction common. In the UK in 2015, more than 142,000
in exposure to the main risk factor, UV new cases were diagnosed, including about 80%
radiation. Primary care clinicians can play BCC and 20% SCC [6, 7]. Similar to melanoma,
an important role in skin cancer the incidence of KCs has risen over recent dec-
prevention through tailored advice about ades, with an increase of 61% over the past
the risks of UV exposure. 10 years alone [6].
In the UK, most patients with skin cancer
This article focusses on the most common first present in primary care [8], where clinicians
types of skin cancer: melanoma, then face the challenge of distinguishing a rare
squamous cell carcinoma and basal cell possible skin cancer from common benign skin
carcinoma. We describe the main risk lesions [9]. The National Cancer Diagnosis
factors and prevention advice. We Audit in England recently reported that the
summarise key guidance on the symptoms median primary care interval (time from first
and signs of skin cancers and their presentation to referral) for melanoma was
management, including their initial 0 days, the joint lowest of the 21 cancers
assessment and referral. reported [10]. Prolonged intervals of 60 and
In addition, we review emerging 90 days were experienced by 6% and 4.8% cases
technologies and diagnostic aids, which at respectively [10], suggesting that primary care
present require more evidence for their clinicians are generally accurate at recognising
safety and efficacy, but may become suspicious skin lesions. However, among
available for use in primary care in the patients referred with suspicious skin lesions via
near future, to aid the triage of suspicious an urgent suspected cancer ‘2-week-wait’
skin lesions. (2WW) system in England, only around 3% are
diagnosed with melanoma [11], suggesting that
improved primary care triage could reduce
burden on both patients and specialist care.
BACKGROUND Although this article principally aims to support
primary care clinicians in the UK to recognise
Skin cancer, including melanoma, basal cell and manage patients with possible skin cancer
carcinoma (BCC) and cutaneous squamous cell in a timely way, it will also be of relevance to
carcinoma (SCC), has one of the highest global clinicians in other healthcare systems. We
Adv Ther (2020) 37:603–616 605

focused on the National Institute for Health and melanoma and KCs are listed in Fig. 1
Care Excellence (NICE) guidelines, developed [12, 16–21].
for use in England and Wales, to direct the
discussion. We present melanoma and the ker-
atinocyte carcinomas separately, except when PREVENTION
their assessment and management can be con-
sidered together. Prevention of skin cancer focuses on patient
This article is based on previously conducted education about the risks and benefits of sun
studies and does not involve any new studies of exposure, and tailoring advice to the individual
human or animal subjects performed by any of patient risk [22, 23]. Figure 2 provides a sum-
the authors. mary of advice on avoiding sun exposure
[22–25]. A systematic review exploring complex
risk communication, undertaken to support
RISK FACTORS NICE guidelines on sunlight exposure [22],
found that only tailored messages (i.e. person-
Skin cancer incidence relates strongly to age, alised to individual circumstances) had strong
with age-specific incidence rates rising sharply evidence as a potentially effective strategy for
from 50 years to peak in those over 75 years of improving health behaviour outcomes. Relative
age. In contrast to most other cancers, 25% of risk reduction (i.e. the relative decrease in the
melanomas are diagnosed in those aged 50 and risk of an adverse event in the group adhering to
under [12]. The main risk factor for all skin preventative advice compared to the group not
cancers is preventable, namely exposure to following preventative advice) was thought to
ultraviolet (UV) radiation, with more than 80% be more persuasive in getting people to adopt
of melanomas attributed to UV exposure certain behaviours than other statistical pre-
[13, 14]. This includes not only long-term sentations. There is evidence that interventions
exposure but also short periods of intense sun based on the appearance-damaging effects of
exposure or burning, especially in childhood or UV exposure, and the positive effects of sun
with sunbed use. For SCCs, cumulative UV protection, may be effective in altering beha-
exposure appears to be the main risk factor, viour [26]. Cancer Research UK have produced
whereas intermittent UV exposure is the leading numerous patient information resources as part
risk factor for BCCs [15]. Other risk factors for of their Sun Smart campaign [27], which can be

Fig. 1 Risk factors for melanoma and KCs

606 Adv Ther (2020) 37:603–616

Fig. 2 Advice to give patients aiming to reduce sun exposure and risk of skin cancer [22–25]

used by clinicians to aid communication with has changed in size, shape or colour [35] (Fig. 3).
patients. It most commonly presents on the trunk in men
and on the legs in women [12]. Other mela-
noma subtypes include nodular melanoma
SCREENING (5%), lentigo maligna (melanoma in situ,
4–15%), and acral lentiginous melanoma (5%)
There is no evidence worldwide to support the [36, 37] and these may present in different
use of screening programs at a population level ways.
[28, 29], although there is recent research Nodular melanomas tend to occur on the head
interest in using risk assessment models to and neck of older people: they grow quickly,
identify people at higher risk of melanoma, for and are usually firm, symmetrical and evenly
personalised approaches to surveillance [30–32]. pigmented papules or nodules, which may
Guidelines in the USA recommend screening for ulcerate and bleed.
patients at high risk of melanoma due to a Lentigo maligna (also known as Hutchinson’s
strong family or personal history of skin cancer freckle) develop as a slow-growing precursor
[33], and the Royal Australian College of Gen- pigmented macule which may remain in situ for
eral Practitioners’ guidance suggests a many years. Once it becomes invasive it is
6-monthly full-skin examination for patients at known as lentigo maligna melanoma and may
high risk of melanoma and annually for those at progress rapidly, often being poorly defined and
high risk of KC [25]. Interestingly, a recent sys- variably pigmented; they are much more com-
tematic review assessing BCC screening against mon in people aged 60 and over.
the World Health Organisation screening crite- Acral lentiginous melanomas occur exclusively
ria [34] concluded that it may be beneficial for on the palms and soles and under nails, and are
lesions on the face. thought to be unrelated to sun exposure.
Although uncommon among Caucasians, they
are commoner in people with pigmented or
DETECTING SKIN CANCER Asian skin. They typically appear as a large
IN PRIMARY CARE pigmented macule, but can mimic warts with a
verrucous, non-pigmented appearance [38–40].
Melanoma An estimated 2–20% of melanomas are
amelanotic—these can appear as a non-pig-
Symptoms and Signs mented mimic of any subtype, with nodular
The commonest subtype of melanoma is known melanomas the most likely to be amelanotic
as superficial spreading melanoma: this classically [38]. They are more common in older age
presents as a pigmented skin lesion (‘mole’) that groups over 70 years of age and in the head and
Adv Ther (2020) 37:603–616 607

Fig. 3 Clinical images of types of melanoma. a Superficial melanoma. The images are reproduced with the kind
spreading melanoma. b Nodular melanoma. c Amelanotic permission of the Primary Care Dermatology Society and
melanoma. d Lentigo maligna. e Acral lentiginous are available on their website: http://www.pcds.org.uk/

neck region, and tend to have worse outcomes 3 or more, then referral via an urgent suspected
than pigmented melanomas [38]. cancer pathway is recommended [41]. There are
a number of other checklists available, such as
Management the ‘‘ABCDE’’ mnemonic, most commonly used
NICE guidance (2015) recommends using naked in North America, which refers to Asymmetry,
eye examination and the weighted Glasgow Border irregularity, Colour variation, Diameter
7-point checklist to assess suspicious skin larger than 6 mm, Evolution/changing [43, 44].
lesions (see Fig. 4; [24, 41, 42]). If a lesion scores NICE recommends that a suspected melanoma
608 Adv Ther (2020) 37:603–616

Fig. 4 a Weighted Glasgow 7-point checklist for assessing that do not require referral to secondary care (unless there
suspicious pigmented skin lesions, as recommend by NICE are other concerning symptoms) as they suggest a benign
guidance (2015) [41, 42]. b Reassuring clinical features lesion [24]

should not be excised in primary care [45], pigmentation under the nail; or any skin lesion
although a recent study suggests that no harm that is persistent or slowly evolving and unre-
came to patients undergoing primary care sponsive, with an uncertain diagnosis [24].
excision in the rural Scottish setting [46]. To A routine referral for risk estimation, educa-
avoid missing atypical melanomas, the NICE tion and possible surveillance should be con-
clinical knowledge summary also recommends sidered for anyone who is potentially at high
referring the following lesions via an urgent risk for developing melanoma. This includes
suspected cancer pathway: new nodules which those who have giant congenital pigmented
are pigmented or vascular in appearance; nail naevi (benign melanocytic naevi originating in
change such as a new pigmented line or utero measuring greater than 20 cm in diameter
Adv Ther (2020) 37:603–616 609

b Fig.5 Clinical images of types of SCCs. a Well-differen-

tiated SCC. b SCC on scalp. c Poorly differentiated SCC.
d Keratoacanthoma. The images are reproduced with the
kind permission of the Primary Care Dermatology Society
and are available on their website: http://www.pcds.org.
uk/

[47]), a family history of three or more mela-

noma cases, more than 100 normal moles, or
any atypical moles (particularly if multiple)
[24].

Squamous Cell Carcinoma (SCC)

Symptoms and Signs

SCCs tend to arise in areas that are frequently
exposed to the sun: face, scalp, ears, neck, and
upper limbs [48] (Fig. 5). Typically, they appear
either as an indurated (firm), nodular, crusted
lesion, or as an ulcer with no crusting [49, 50].
However, their appearance is variable and they
should be suspected in any lesion that is larger
than 1 cm, is non-healing, keratinized or crus-
ted, and has a documented expansion over the
past 8 weeks [51]. In situ SCC (Bowen’s disease)
typically appear as erythematous, scaly plaques
with clearly defined margins, but can some-
times be pigmented and flat with poorly defined
margins [19]. A variant of SCC is keratoacan-
thoma; these are domed, fast-growing, nodules
with a central hyperkeratotic region [52]. High-
risk SCCs include those on the lips, ears, non-
sun-exposed sites, in areas of previous injury,
those that are larger than 2 cm in diameter, are
in immunocompromised patients, or are a
recurrence of a previously treated lesion. These
have a higher probability of metastasis and
recurrence after treatment [45].

Management
As for melanoma, confirmation of an SCC relies
on excision and histopathological examination;
therefore all patients with a suspicious lesion
should be referred on an urgent suspected can-
cer pathway to secondary care [41].
610 Adv Ther (2020) 37:603–616

Fig. 6 Clinical images of types of BCC. a BCC. b Super- the kind permission of the Primary Care Dermatology
ficial BCC. c Morphoeic BCC. d Pigmented BCC. Society and are available on their website: http://www.
e Basosquamous BCC. The images are reproduced with pcds.org.uk/
Adv Ther (2020) 37:603–616 611

Basal Cell Carcinoma (BCC) mixed BCC and SCC characteristics and can be
more aggressive than other forms of BCC
Symptoms and Signs [53, 55, 56].
BCCs commonly arise in the head, neck, trunk
and limbs [20], but can be variable in their Management
clinical presentations (Fig. 6). There are several The 2010 NICE guidance recommends that low-
histological subtypes [53] which may present risk BCCs (see Fig. 7) may be excised by primary
differently. Nodular and micro-nodular BCCs are care clinicians with appropriate training
commonly found on the face and present as [53, 57]. This guidance may vary by local
pearly pink or white cystic papules or nodules agreement, depending on the clinicians’ role,
that have telangiectasia on their surface and competencies and local policy. For all other
may be ulcerated. Superficial BCCs are usually on patients with a suspected BCC, routine referral
the upper trunk and shoulders, and present as to specialist care is recommended, although, if
erythematous, well-demarked, scaly plaques there is concern that a delay in referral will
with pearly white borders. They are often large make a ‘‘significant impact’’ because of factors
([ 20 mm), multiple and slow growing, and can such as lesion site or size, then referral via an
be confused with Bowen’s disease. Another urgent cancer pathway should be considered
important mimic is amelanotic melanoma, [41].
which can present as a red lesion and be con-
fused with a BCC [54]. Morphoeic BCCs (also Tools for Evaluating Suspicious Skin
known as sclerosing or infiltrative) usually Lesions in Primary Care
occur on the face and present as skin-coloured,
waxy, scar-like lesions; they tend to recur and
Dermoscopy
can infiltrate cutaneous nerves. Pigmented BCCs
A dermatoscope is a handheld magnification
are brown, blue or greyish lesions that can
tool and light source which eliminates skin
resemble melanomas. Baso squamous BCCs have

Fig. 7 Features of low-risk BCCs [53]

612 Adv Ther (2020) 37:603–616

surface reflection, and can help assessment of set in UK general practice. The MoleMate sys-
skin lesions with visualisation of deeper sub- tem was not found to improve appropriateness
surface structures [58]. Dermoscopy performed of referral, and its use led to a higher proportion
by trained specialists is both more sensitive and of lesions being referred [65]. However, there
specific in classifying skin lesions than clinical was some evidence that a higher referral rate
examination with the naked eye alone [59, 60]. from general practice may actually be cost-ef-
There have been two recent Cochrane reviews fective owing to improved outcomes associated
of the evidence for dermoscopy to diagnose with earlier diagnosis of melanomas [66].
keratinocyte carcinomas [61] and melanoma
[62]. Both found that most evidence was Artificial Intelligence (AI)-Supported Systems
derived from secondary care populations; The use of AI/machine learning to evaluate skin
hence, there was insufficient evidence to sup- lesions has received a huge amount of recent
port routine use of dermoscopy by primary care attention in both the lay and medical press.
clinicians. Our group’s recent systematic review Experimental studies using images of lesions
of dermoscopy use in primary care also found from specialist clinics have shown that AI
the literature to be scanty; however, there was algorithms can classify images of skin cancer
some evidence that dermoscopy has the with an accuracy that matches or even exceeds
potential to help primary care clinicians triage dermatologists [67, 68]. This suggests that AI
suspicious lesions [63]. It also highlighted that has the potential to assist primary care clini-
further evidence is needed on patient accept- cians to triage suspicious skin lesions; research
ability and minimum training requirements for is now needed on real-world primary care pop-
primary care clinicians to reach competence, as ulations to establish the accuracy and safety of
well as the cost-effectiveness of implementing using these AI technologies in primary care.
dermoscopy in primary care.
Other Diagnostic Tools
Teledermatology Many other non-invasive tests and diagnostic
This term describes the use of information technologies have been developed to aid skin
technology to facilitate skin management, most cancer diagnosis, including high frequency
commonly by sharing digital images of lesions ultrasonography, optical coherence tomogra-
with dermatology specialists. Teledermatology phy, reflectance confocal microscopy, and
referral systems are already well established in computer-assisted diagnosis. They have been
some areas of the UK. A recent Cochrane review evaluated in several recent Cochrane reviews,
assessing the diagnostic accuracy of telederma- all of which found a paucity of evidence for
tology for detecting melanomas, BCCs and their accuracy in either primary or specialist
SCCs in adults compared to face-to-face diag- care settings. Therefore, at present, there is
nosis by a specialist concluded that telederma- insufficient evidence to recommend their use
tology is accurate for identifying the majority of [64, 69–73].
malignant lesions [64]. However, it also sug-
gested that further research is needed to fully
determine its diagnostic accuracy, feasibility CONCLUSIONS
and cost-effectiveness as a triaging tool for
referring suspicious skin lesions from primary to Advice on limiting sun exposure remains an
secondary care. important task for primary care clinicians,
especially among high-risk patient groups. Any
SIAscopy/MoleMate System suspected melanomas or SCCs should be refer-
Spectrophotometric intracutaneous analysis red via urgent cancer pathways to specialist care
(SIAscopy) is a non-invasive scanning technol- for histological diagnosis and management.
ogy, incorporated into the MoleMate system, Suspected BCCs should be referred routinely to
and evaluated in a randomised controlled trial specialist care unless they are of concern
Adv Ther (2020) 37:603–616 613

because of their size or location, when they may Compliance with Ethics Guidelines. This
warrant urgent referral. article is based on previously conducted studies
A number of diagnostic technologies are in and does not involve any new studies of human
development, some of which may have a sig- or animal subjects performed by any of the
nificant impact on clinical practice. We may authors.
therefore be on the verge of significant changes
in the detection of possible skin cancers in pri- Open Access. This article is distributed
mary care. However, the evidence for the safe under the terms of the Creative Commons
and effective use of most of these technologies Attribution-NonCommercial 4.0 International
by primary care clinicians is currently lacking. License (http://creativecommons.org/licenses/
There is weak evidence for use of dermoscopy by-nc/4.0/), which permits any non-
and teledermatology in primary care, but even commercial use, distribution, and reproduction
these approaches require further evaluation in any medium, provided you give appropriate
before they can be recommended for wide- credit to the original author(s) and the source,
spread implementation in primary care. provide a link to the Creative Commons license,
and indicate if changes were made.

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