Duties and responsibilities
Pitfalls in the diagnosis and management of skin cancer
Originally published September 2012
Non-melanoma skin cancer, which includes both basal and squamous cell carcinomas, is the most common cancer diagnosed in Canada. Fortunately, the associated mortality is very low. On the other hand, melanoma skin cancer is diagnosed less frequently, but the rate of mortality is much higher.1 Management of both skin cancer types can present patient safety and medico-legal issues.
The CMPA reviewed its legal and medical regulatory authority (College) cases from 2007 to 2011 that related to skin cancer. Thirteen different physician groups were associated with the cases — family physicians were involved most often, followed by dermatologists, and plastic surgeons. In the closed College cases, 73% ended in the College expressing concern about the patient care, and in the closed legal actions, 29% resulted in a settlement.
Assessment and treatment issues
A woman with a history of actinic keratoses, basal cell carcinoma, and melanoma in situ saw her family physician for an assessment of a skin lesion on her shoulder.
The family physician completed a cursory examination and did not document the presence of the shoulder lesion. The patient returned 2 months later and requested a referral to a dermatologist. When seen several months later, the dermatologist noted a large reticulate black patch with satellite dark macules on the patient's shoulder. Biopsy revealed melanoma in situ. The patient complained to the College, alleging the family physician inappropriately dismissed her concern about the shoulder lesion.
The College concluded the lesion on the woman's shoulder should have been detected and acted upon when she first presented to the family physician. The College cautioned the family physician to complete a full skin examination as part of a general physical examination of patients with a history of malignant melanoma.
Other assessment and treatment issues
Other assessment and treatment issues identified by peer experts in the reviewed cases include:
- not considering a diagnosis of skin cancer, thereby missing the opportunity for biopsy, particularly in the presence of a non-healing skin lesion
- not sending a specimen for pathology when a lesion was thought to be of concern
- pathologist failing to recognize atypical findings in a specimen
- not performing a re-excision of a cutaneous malignancy after an initial excision with inadequate margins
- delay in referring a patient for a biopsy
- failure to expedite a referral appropriately
Informed discharge and follow-up issues
A 60-year-old man was referred by his family physician to a consultant for assessment of a painful, draining great toe nail of 3 months duration.
Examination revealed a soft nail with slight erythema and exudate. After ruling out infection, the consultant performed a simple nail resection. The nail and tissue fragments were sent for histopathology. The dermatopathologist described the presence of atypical cells as "worrisome" and recommended follow-up with further nail bed sampling. The consultant advised the patient about the abnormal cells and the need for a nail bed biopsy if the nail grew back in the same manner. When this occurred, the consultant instructed the patient to schedule a convenient time for the recommended biopsy. Details of the discussions with the patient were not documented, nor did the consultant advise the family physician of the treatment plan. When the patient failed to make an appointment for the biopsy, no attempt was made to contact the patient.
Approximately 4 years following the initial presentation, malignant melanoma of the first toe nail bed with inoperable liver metastases was diagnosed. The patient filed a complaint with the College.
The College acknowledged the extreme difficulty in diagnosing melanoma beneath the toe nail. Although it believed the medical record reflected the need for a nail bed biopsy in light of the atypical cells, the lack of details about the discussion with the patient caused the College to question whether the physician effectively conveyed "the fundamental importance of such follow-up, and the consequences of failing to comply with the same." The College was also critical that the physician did not attempt to contact the patient when the patient failed to schedule the planned biopsy.
Other issues with informed discharge and follow-up
Other issues related to informed discharge and follow-up identified by peer experts in the reviewed cases include:
- not providing adequate patient education regarding skin changes of concern and when to seek medical attention
- failing to obtain or follow up pathology reports
- filing pathology results before notifying the patient
- not communicating pathology results to patients or to those healthcare professionals involved in the care of the patient's cutaneous malignancy
- disregarding the pathologist's recommendation for a deeper excision
- delaying in referring the patient to a specialist
- failing to follow up consultations with other physicians
- having inadequate office procedures for patient follow-up
A middle-aged woman presented to a family physician for assessment of a lesion on her left temple.
The woman had a history of basal cell carcinoma on her left temple as well as an actinic keratosis. Based on a diagnosis of superficial actinic keratosis, the family physician treated the lesion with liquid nitrogen. Approximately 4 months later, the woman saw a dermatologist due to re-growth of the lesion. A biopsy confirmed basal cell carcinoma. The woman complained to the College.
The College could not determine whether the family physician's management of the lesion was appropriate because the medical record lacked detailed information, specifically, the "history, physical examination, description of the lesion, differential diagnosis, result of the treatment, recommended follow-up, and documentation of instructions provided to [the patient]." The College cautioned the family physician about the importance of documenting pertinent information in the medical record.
Other documentation issues
The peer experts in all the reviewed cases identified other documentation issues including the lack of a diagnostic impression or treatment plan in the medical record or consultation report; inadequate information in the pathology request or in the surgical pathology report; and inaccurate information in the medical record.
Managing the medico-legal risks of skin cancer
The following risk management considerations for physicians are based on the expert opinions in the cases reviewed:
- Consider performing a full skin examination on patients with a history of malignant melanoma.
- Assess if a biopsy is indicated for lesions that are clinically suspicious for a cutaneous malignancy.
- Follow up on biopsy results and communicate pathology results to patients and to those healthcare professionals involved in the care of the patient's cutaneous malignancy.
- Make reasonable efforts to ensure appropriate follow-up is arranged. If applicable, act on or carefully evaluate the pathologist's recommendation for re-excision.
- If warranted, refer the patient to an appropriate specialist.
- Teach patients to recognize skin changes that require medical attention.
- Convey to patients the importance of follow-up.
- Complete the medical record to accurately reflect the diagnostic impression and management of the skin lesion.
- Canadian Cancer Society's Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012. p.7-9.