Skin Cancer Clinical Advisory Group – Information for CAG Members

COVID-19 Management Plans
Skin Cancer Management Guidance in Response to COVID
Dermatology COVID 19 surgery procedures v3
http://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=6658

Skin Cancer CAG Key Documents:
These are living documents that will be continually reviewed and updated.
Please refer to the version control table to see the current status.
SWAG_Skin_Cancer_Clinical_Guidelines_2022 (review underway)
SWAG_Skin_Cancer_Constitution_2022 (review underway)
SWAG_Skin_SSG__Annual_Report_2015
SWAG_Skin_SSG__Annual_Report_2016_17
Management_of_Palpable_Node_in_ Skin_Cancer
Transplant_Skin__Clinic_Surveillance_Visit
Renal_Transplant_Baseline_Dermatology_Risk_ Assessment

Bristol Mohs Micrographic Surgery Service:
SWAG Bristol Mohs referral contact details v1.2
SWAG Bristol Mohs Guidelines text v1.2
SWAG Bristol BCC and Mohs Guidelines flowchart v1.2
Bristol_Mohs_Patient_Information_Leaflet v1.5

Update on Bristol Mohs service Feb 2021

In Feb 2020 we marked our 5th anniversary of the Bristol Mohs service. We had built the service up to 3 Consultants, thereby offering 3 full days of Mohs surgery per week. Our waiting time once listed for Mohs surgery was then around 4 months for average cases, and quicker if urgency necessitated.

Since then a degree of backlog has developed due to the reduced service throughput caused by the pandemic, so the wait has increased to around 4-6 months currently, but is about to lengthen.

I regret to inform you that we will only be able to offer a third of the previous capacity for the time being, since one of my colleagues is now on maternity leave, and the other is having to move to another city for family reasons. Needless to say we are working on recruitment and increasing capacity, but the situation may take some time to improve.

Whilst we are anxious not to reduce access for those who will benefit most from having Mohs, clearly the waiting list could extend to unacceptable levels, which would affect the balance of risks. Some patients would still be best served by waiting a year or more for Mohs, but others might be better off having a standard excision with a wider margin earlier.

Therefore the following is a decision aid to help you discuss treatment decisions with your patients and at MDT. If you are unsure please do discuss the case in detail at the MDT and I am available on email for any difficult cases that the MDT would like some advice on. I would need images to give advice.

Please discuss at your MDTs and refer appropriate cases, having also warned patients of the likely delay in treatment.

Some patients may wish to be referred to the next most appropriate Mohs service to their location, if the waiting list is shorter e.g. Exeter, Salisbury, Worcester, Oxford.

Usual Indications for Mohs (mainly for BCC, also for certain SCC or rarer tumours)

• Poorly defined borders
• Anatomical location:
  • ‘H-zone’ (high risk of recurrence)
  • Sites where sparing tissue highly important
• Recurrent
• Incompletely excised
• Infiltrative/morphoeic/micronodular BCC or rarer aggressive infiltrating tumours e.g. MAC

Supplementary advice under current restrictions

Recommend referring for Mohs (estimated wait 6-12 months for average case; can be prioritised sooner if urgent)

Primary BCC threatening important anatomy
Poorly defined edges/infiltrative BCC in H zone
Any BCC incompletely excised more than once (including once by experienced skin cancer surgeon)
Re-excision with wide margins will be excessively disfiguring or force unsatisfactory reconstruction/delayed repair
Rarer aggressive infiltrating tumours in the H zone e.g. MAC

Recommend considering standard excision in local unit to avoid potential harm from delay

Well-defined primary nodular BCC on lower third of nose
Well-defined primary nodular BCC on lower eyelid but away from lacrimal punctum
Primary infiltrative BCC on face/scalp but away from H zone and well-defined edges

Best wishes

Dr Adam Bray

Consultant Dermatologist
Dermatological & Mohs Surgeon

Best email for advice: adam.bray@nbt.nhs.uk

Research:
Clinical Trials 2019

Useful Links:
The West of England Clinical Research Network
http://www.crn.nihr.ac.uk/west-of-england/

The Somerset Cancer Register (SCR)
http://nww.cancerreg.somersethis.nhs.uk/default.aspx

The National Cancer Research Institute Clinical Studies Group (NCRI) – Portfolio Maps
http://csg.ncri.org.uk/portfolio-maps/