STEP 2: Presentation, initial investigations and referral

This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.

The following signs and symptoms should be investigated by a general practitioner:

  • any new or changing skin lesions or lesions that do not respond to treatment
  • a rapidly growing skin lesion that remains unresolved after one month.

SCCs arise on the background of sun-damaged skin characterised by actinic keratoses. The following symptom should be investigated for SCC:

  • induration (thickening) or tenderness in the erythematous base of a scaling lesion.

The following signs and symptoms should be investigated for BCC:

  • a dome-shaped skin lesion
  • a pink or red scaly patch
  • waxy or pearly hard skin-coloured lesion
  • a sore that will not heal or with blood vessels.

The presence of multiple signs and symptoms, particularly in combination with other underlying risk factors, indicates an increased risk of keratinocyte cancer.

Presenting symptoms should be promptly and clinically triaged with a general practitioner.

General practitioners provide the majority of care for patients with keratinocyte cancer, either in a general practice setting or at a skin clinic.

General practitioner examinations and investigations should include:

  • history and clinical examination, including a whole-body skin check utilising dermoscopy (beyond just the primary lesion of concern)
  • a diagnostic or curative biopsy of any lesions with suggestive/concerning clinical features, which can be conducted by a general practitioner with experience and confidence in surgical procedures for:
  • well-defined primary lesions of the trunk and extremities – large lesions can be difficult to excise, and the patient may need a referral depending on the circumstances
  • well-defined primary lesions of the face, forehead or scalp – large lesions, or where removing a lesion may compromise aesthetic outcome may need referral
  • consideration of underlying patient factors, and applying an observational approach if the patient’s quality of life is unlikely to be improved by definitive removal of an asymptomatic lesion.

For most lesions the best approach is complete excision. Uncomplicated small lesions are best removed by an elliptical excision with a 3–4 mm margin (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019; Clarke 2012). If complete excision is not considered appropriate, small representative samples, such as by one or more punch biopsies, shave biopsy or curettage, can be useful.

Most BCCs that are clinically favourable (e.g. small, nodular or superficial types not located in the central face) can be satisfactorily excised under local anaesthetic with direct primary closure in an ambulatory care setting.

Biopsy-proven superficial BCCs that are not suitable for excision (e.g. cosmetically sensitive sites or lower legs with risk factors for poor healing) may be considered for non-surgical therapies such as topical imiquimod cream, photodynamic therapy or radiation therapy. Likewise, an SCC in situ or superficial BCC may be treated with topical 5-fluorouracil cream under similar situations. Patients receiving these treatments must be made aware of the need for follow-up of the treated site(s) to check for lesion recurrence.

Actinic keratoses that persist following cryotherapy, enlarge or become tender should be reassessed and biopsied if clinically indicated.

Investigations and/or curative treatment should be performed within four weeks of initial presentation to a general practitioner or as soon as practicable.

Lesions that are in more sensitive sites (e.g. head and neck), or have more aggressive features (see section 2.3 for a comprehensive list of high-risk/complicated cancers) will dictate promptness of review.

Most BCCs or SCCs do not require referral.

For a complicated BCC, consider referral to a dermatologist or surgeon if the following apply:

  • incompletely excised lesions where surgical expertise is required for appropriate margins or lesions with a high risk of recurrence (particularly if the BCC is shown to be infiltrative or morphoeic)
  • lesions involving the central face, ears, genitalia, digits, palm of hand or lower leg
  • poorly defined lesions
  • lesions fixed to underlying structures
  • lesions involving or lying adjacent to significant nerves – for example, a facial or accessory nerve
  • large lesions (especially on the head and extremities) (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019)
  • neurotropic spread
  • lymphovascular invasion.

For a complicated SCC, consider referral for the following:

  • SCC of the central face, scalp, lip, ear or genitals
  • lesions greater than 20 mm in diameter or deeper than 6 mm
  • chronically immunosuppressed patients with multiple aggressive SCCs
  • head and neck SCCs that are histologically aggressive on biopsy (e.g. moderately and poorly differentiated, neurotropic or vascular invasion)
  • locally recurrent and persistent SCC and/or inadequately treated SCC (Cancer Council Australia Keratinocyte Cancers Guideline Working Party 2019).

Patients should be enabled to make informed decisions about their choice of practitioner or specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.

Referral for suspected or diagnosed keratinocyte cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:

  • important psychosocial history and relevant medical history
  • family history, current symptoms, medications and allergies
  • results of current clinical investigations (imaging, photographic landmarks/digital photography and pathology reports)
  • results of all prior relevant investigations
  • notification if an interpreter service is required.

Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.

If access is via online referral, a lack of a hard copy should not delay referral.

The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.

Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources Checking for cancer and Cancer from the Cancer Australia website.

If a diagnosis is required referral to specialist should be as soon as is practicable according to clinical concern (e.g. four weeks for a presumed SCC and eight weeks for a presumed BCC).

If the patient is not seen within an appropriate timeframe, the referring practitioner needs to follow this up with the specialist.

The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific needs may arise for patients at this time:

  • assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
  • encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).

For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.

For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.

The general practitioner is responsible for:

  • providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
  • requesting that patients notify them if the specialist has not been in contact within the expected timeframe
  • considering referral options for patients living rurally or remotely
  • supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse).
More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.