ORIGINALPAPER
Adherencetothemultiprofessionalguidelines
forthemanagementofprimarycutaneoussquamouscellcarcinoma:are-auditofUKplasticsurgeons
S.J.Hemington-Gorse&J.J.Staiano&S.K.Dhital&F.S.Fahmy&D.D.McGeorge&A.M.Juma
Received:27May2006/Accepted:21June2006/Publishedonline:7October2006#Springer-Verlag2006
AbstractInJanuary2002multiprofessionalguidelinesforthetreatmentofsquamouscellcarcinomawerepublishedbytheBritishAssociationofDermatologyinconjunctionwiththeBritishAssociationofPlasticSurgeryandmembersoftheFacultyofClinicalOncologyoftheRoyalCollegeofRadiologists.InJuly2002asurveywasundertakenwhichdemonstratedthatdespitetheavailabilityoftheseguidelines,therewasnoconsensusofopinionregardingthetreatmentofsquamouscellcarcinomaamongstUKplasticsurgeons[StaianoJJ,JumaA,DhitalSK,McGeorgeDDEurJPlastSurg27:1352004].Itisnow3yearssincetheguidelineswerepublished,andwehavere-auditedUKplasticsurgeonstodeterminewhetherthepublishedguidelineshaveaffectedthetreatmentofthiscommoncutaneousmalignancy.OurfindingsonceagaindemonstratethattheguidelineshavehadlittleeffectonclinicalpracticeandthatthetreatmentofcutaneoussquamouscellcarcinomavarieswidelyamongstUKplasticsurgeons.
KeywordsSquamouscellcarcinoma.Guidelines.Excisionmargins
Introduction
Itiswelldocumentedthatnon-melanoticskincancerismorecommonthananyothercancerofthehumanbody[2],withanestimated2.75millionnewcasesdiagnosedworldwideperyear[3].Datasuggestthatnearly1,000,000basalcellcarcinomas(BCCs)and250,000squamouscellcarcinomas(SCCs)werediagnosedintheUSAin2002[4].During2002theincidenceofBCCandSCCalmostequalledtheincidenceofallothercancerscombined[5].BCCsareapproximatelyfivetimesmorecommonthanSCCs,withSCCsaccountingfor∼20%ofalldermatologicalmalig-nancies[3].Althoughthemortalityratefromnon-melanoticskincancerislow[3],thetendencyofSCCtometastasizemeansthatitcontributessubstantiallytomorbidityandmortalityamongsttheelderlypopulation[6,7].
InJanuary2002theMultidisciplinarySkinCancerCommitteerepresentingtheBritishAssociationofDerma-tology,theBritishAssociationofPlasticSurgeryandmembersoftheFacultyforClinicalOncologyoftheRoyalCollegeofRadiologistspublishedguidelinesonthemanagementofprimarycutaneousSCC(Fig.1.)[8].ThiscoincidedwiththepublicationofguidelinesfromtheRoyalCollegeofPathologistsregardingtheminimumdatasetforthehistopathologicalreportingofcommonskincancers[9].Usingthestandardssetbythesedocuments,weundertookanauditofUKplasticsurgeonsinJuly2002[1]todeterminewhetherthetreatmentofSCCwasstandardisedintheUKandwhetheritadheredtopublishedguidelines.Ourfindingssuggestedthatdespitetheguide-lines,treatmentremainedsurgeon-dependentwithoutaconsensusofopinion.Itisnow3yearssincetheguidelineswerepublished,andwethereforere-auditedUKplasticsurgeonstodeterminewhethertheguidelineshavebecomemorewidelyacceptedandarebeingfollowed.
S.J.Hemington-Gorse(*)
DepartmentofPlasticSurgery,WelshCentreforBurnsandPlasticSurgery,MorristonHospital,SwanseaSA66NLWales,UKe-mail:sgorse@doctors.org.uk
J.J.Staiano:S.K.Dhital:F.S.Fahmy:D.D.McGeorge:A.M.Juma
DepartmentofPlasticSurgery,CountessofChesterHospital,ChesterCH21UL,UK
158
Fig.1Multiprofessionalguide-linesforSCCexcision
EurJPlastSurg(2006)29:157–161
Lesion SCC
Site & Diameter of lesion eyelids, scalp) Any diameter
Excision margin
High risk (ear, lip, nose, >6mm excision
SCC SCC
Low risk site >2cm diameter Low risk site <2cm diameter
>6mm excision 4mm excision
Materialsandmethods
Twohundredandninety-sixconsultantplasticsurgeonswereidentifiedfromtheBritishAssociationofPlasticSurgeonsmembershipdatabase.Aquestionnaireandapersonalisedcoveringletterweresenttoeachconsultantexplainingthenatureoftheaudit.Astampedaddressedenvelopewasalsosentouttofacilitatereturnofquestion-nairestotheauditdepartment.Thequestionnairesentoutwasidenticaltoourpreviousquestionnairetoallowdirectcomparisonofresults,withonesimpleadditionalquestionaskingwhethertheguidelineshadchangedthesurgeons'practice[1].Asecondmailshotofquestionnaireswasdistributed3monthsafterthefirsttoimproveresponserate.Thefollowingquestionswereasked:––––––––
DoyouhaveastandardexcisionmarginforSCC?Ifyes,whatisit?
Ifno,isitaffectedby(a)diameteroflesion?(b)siteoflesion?
Ifsiteoflesionaffectsthemargin,whichsitewarrantswiderexcision?
Wouldyouconsiderre-excisingacompletelyexcisedSCC?
Ifyes,isthisaffectedby(a)histologicalmargins?(b)thicknessoflesion?
Whichofthefollowingroutinelyappearonpathologyreports?
Havethe2002guidelinesaffectedyourpractice?
Results
Onehundredandsixty(54.1%)completedformswerereturnedtotheauditdepartmentattheCountessofChesterHospital.Asourpreviousstudysuggested,thereremainsanalmostequalsplitbetweenplasticsurgeonsintheUKregardingtheuseofastandardexcisionmargin(Fig.2).Ofthoseusingastandardmargin,46.4%use5mmand34.8%use6mmormore(Fig.3).
Ofthosewhostatedthattheydidnotuseastandardmargin,75%respondedthatthediameterofthelesioninfluencedthemarginand92%feltthatthesiteofthelesionisimportantindeterminingthenecessarymargin,withsomesurgeonsinfluencedbyboth(Fig.4).Asinour2002study[1],awiderexcisionwaslikelytobetakenonthetrunkandlimbsdespitetheavailabilityofevidencetosuggestthattheheadandneckregionisatmostriskformetastasisandincompleteexcision[8,10,11](Fig.5).Sixty-twopercentofsurgeonsfeltthatare-excisionofacompletelyexcisedSCCwassometimeswarranted(Fig.6).Whilstinthemajorityofcasestheclosenessofthemargingovernedthisdecision(97%),thethicknessofthelesionwasalsorecognisedtobeimportant(57.6%)(Fig.7).Thisisincontrasttoourpreviousfindingswhereonly39%feltthatthicklesionsshouldbere-excised.
excision margins50403020100noot rtheecrordedmmmm2m3m4m5m6mmSeries1consensus of excision marginyesnoothernot reordedFig.2Consensusofexcisionmargins
%margin (mm)Fig.3Excisionmargins
EurJPlastSurg(2006)29:157–161influence of diameteryesnonot recordedinfluence of siteyesnonot recordedFig.4Importanceofsiteanddiameteronmarginofexcision
Whenpathologyreportsareconsidered,itwouldappearthatthemarginofexcisionandthedegreeofdifferentiationremainwellrecorded(89%and87%,respectively).However,itwouldappearthatreportingofothercharacter-isticssuchashistologicalgrade,thicknessandlevelofdermalinvasionhasimproved(22.5%,47.5%and26.9%,respectively,cf.15.1%,36.7%and12.2%in2002)(Fig.8).Whetherthisrepresentsatruechangeinreportingoranincreaseinthesurgeons'perceptionoftheimportanceoftheseaspectsisdifficulttodeterminewithoutreviewinghistologyreportsfromallcentresourselves.
Perhapsunsurprisingly,only32.5%ofUKplasticsurgeonsfeltthattheintroductionofguidelineshadaffectedtheirmanagementofprimarycutaneousSCC;59.4%statedthattheirpracticehadnotalteredpostguidelines.Amongstthenumerousfree-handcommentsrelatedtothisquestion,itbecameclearthatthemajorityofsurgeonsfeelthatthe
sites where larger excision would be taken12010080%60Series140200rapeipdlelialsbsenkcmuseyonirltsiteFig.5Siteswherelargerexcisionmarginswouldbetaken
159
? re-excisionyesnonot reordedFig.6Consensusonre-excision
guidelinesactasaframeworkfordecisionmakingbutarenotasubstituteforclinicaljudgement.
Discussion
ItwouldappearthatthemultiprofessionalguidelinesforthemanagementofprimarycutaneousSCC[8]havehadlittleimpactonthemanagementofthismalignancybyplasticsurgeonsdespitetheinvolvementoftheBritishAssociationofPlasticSurgeonsintheirdevelopment.Onceagainwehavedemonstratedalackofstandardisationinthecareofthispatientgroup.
Itiswelldocumentedthattheheadandneckregionisatahigherriskforsubclinicaltumourextensionandrecur-rence[2,8,10,12,13],yetourresultssuggestthatsurgeonsarereluctanttotakeawideexcisionmargininthisarea,with<50%acknowledgingthatthisregionrequiresawiderexcision.Manysurgeonsinfactcommentthattheywouldtakeanarrowermarginonthefacetosalvagecosmeticallyimportantunits.Anotherpossibilityisthatsurgeonsaretryingtoavoidcreatingfunctionalproblems,
importance of marginyesnonot recordedimportance of thicknessyesnonot recordedFig.7Importanceofmarginsandthicknessonre-excision
160100908070605040Series13020100nnnysnligoogsreeiirtoeevdaasltamiaontertkal nvhcpsgi penpkirhlrerotaeecalfidfmi gc &dlleol lacohrteatpaFig.8Pathologicalfeaturesalwaysfoundonhistologyreports
particularlyintheperioralandperiorbitalregions,whichcanleadtolengthycomplexreconstructiveprocedureswhichmaynotbethemostappropriateoptioninanelderlypopulationgroupwhofrequentlyhavemanyco-morbidfactorsmakingthemasignificantriskformajorsurgery.However,aswefoundpreviously,lesionsonthelimbsandtrunkarefrequentlyexcisedwithalarger-than-neededmargin.
Theguidelinessuggestthatlesions<2cmindiameterneeda4-mmexcisionmarginandthose>2cmindiameterorinhigh-riskareas(i.e.headandneckregion)needa6-mmexcisionmargininordertoachievehistologicalclearancein95%ofcases[10,14].Itwouldbeeasytostandardisecarebasedontherecommendations,whichinturnwouldmakeanationalauditandcomparisonofoutcomesfollowingSCCapossibility.However,untilpracticewithintheUKisuniform,thisisunlikelytohappen.Ourresultssuggestthattheguidelinesfortheheadandneckregioninparticularmayneedtobere-examinedsincecomplianceinthisregionislow.Themajorityofsurgeonsstatethat5mmistheirstandardmargin(46.4%),withsomeaddingthatinlargerlesionsuptoa2-cmmarginistaken.Suchwideexcisionsareactingcompletelyoutsidetheguidelinesandlackevidencetosupporttheiruse.Intheeraofevidence-basedpracticeinwhichweareworkingwithincreasedaccountabilityofindividualpractitioners,thiscouldpotentiallyleadtoproblemsfortheoperatingsurgeons.
ThediameterofthelesionisonlyoneaspectindeterminingprognosisfollowingSCC.Thedepthofthetumourisalsoconsideredtobeimportant[13,15–18]andhasbeenrecognisedbytheRoyalCollegeofPathologiststobeanessentialcomponentofreportingonSCC[9].In2002wedemonstratedthatsurgeonsdidnotperceivedepthtobeimportant[1],withonly39%respondingthattheywouldconsiderre-excisionofatumourbasedonitsthickness.
EurJPlastSurg(2006)29:157–161
Thishasrisensharplyto57.6%inourre-audit,perhapsrepresentingatrueimprovementinreporting(47.5%alwaysincludethicknesscf.36%in2002),oritcouldrepresentachangeintheoverallviewofsurgeonsregardingtheimportanceoftumourthicknessasaprognosticindicator.Unfortunatelyapostalquestionnairedoesnotallowforadistinctiontobemadebetweenthesetwopossibilities.
Regretfullythe2002guidelines[8]donotaddressthefollow-upofapatientwithanSCCfurtherthanstatingthatmostrecurrencesoccurwithin5years.Manyunitsadaptthemelanomafollow-upregimetoincludethesepatients,butthereisnofirmevidencebehindthis.Ifthecareofthispatientgroupwasstandardisedtothatrecommended,amulticentreauditwouldbepossibletodeterminetheoptimalexcisionmarginandbestfollow-upregimeforthispatientgroup.ThisinturncouldreducethemorbidityandmortalityfromSCCandimprovethecareofthesepatients.
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