A change in one or more of the ABCDE criteria (asymmetry, border irregularity, colour, diameter of the skin, evolution) and/or the following should be investigated:

• itching, scaling, bleeding, oozing, swelling or pain in a skin lesion
• new lesions, any changing skin lesions or lesions that do not heal or respond to treatment
• a rapidly growing skin lesion that persists after one month
• spread of pigment from a lesion to the surrounding tissue.

Note: A small percentage of cases present as a symmetrical, often non-pigmented nodule that grows progressively for over a month (EFG: elevated, firm and growing progressively).

Initial investigations

Assessments should include taking a lesion history focusing on: how long the lesion has been present; time course if it has changed; the type of change; and associated symptoms (tender, itch, bleeding).

Examinations should be undertaken with good lighting, using a dermatoscope.

Observation, with review, should only occur if there is a low level of suspicion, and only for macular (flat) lesions (to avoid monitoring a nodular melanoma), using dermatoscopic imaging.

Where there is a high level of suspicion, the practitioner should either refer to a specialist or undertake an excisional biopsy. In general, complete excision of the entire lesion with a 2 mm margin should be performed.

If referral is considered the patient should be referred to a dermatologist, skin cancer GP or surgeon who can perform the biopsy.

The following lesions should be referred to a specialist:

• high-risk melanoma (deeply invasive > 1 mm)
• metastatic melanoma
• lesions with histologic uncertainty
• incompletely excised lesions that cannot be treated definitively in primary care.

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.

Communication

The GP’s responsibilities include:

• explaining the diagnosis and the prognostic implications in broad terms
• explaining to the patient and/or carer who they are being referred to and why
• supporting the patient and/or carer while waiting for specialist appointments
• reassuring the patient that if the lesion is a melanoma and completely excised that a short delay to specialist review and treatment is not harmful
• informing the patient and/or carer that they can contact Cancer Council on 13 11 20.

Checklist

Timeframe

If melanoma is suspected, a biopsy or excision should be done within 2 weeks of the initial GP consult, and results provided to the patient within 1 week of the biopsy.

Where appropriate, referral to a specialist should occur within 2 weeks. There will be some patients where management in primary care is appropriate.