2.3 Initial referral

2.3 Initial referral

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.