2.2 Assessments by the general practitioner

2.2 Assessments by the 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.