A skin lesion exhibiting features that match one or more of the ABCDE criteria should be investigated:

• asymmetry
• border irregularity
• colour
• diameter of the skin lesion
• evolving and/or the following:
• itching, scaling, bleeding, oozing, swelling or pain in a skin lesion
• new lesions, lesions noted to be changing or lesions that do not heal or respond to treatment
• a rapidly growing skin lesion persistent after one month
• spread of pigment from a lesion to the surrounding tissue.

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

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; Kelly et al. 2003). These are invasive from the outset and grow more quickly (over weeks to months), with elevation, deeper invasion and earlier onset of bleeding and ulceration.

For patients who present to their general practitioner, either for a routine skin examination or a lesion of concern, a systematic approach to assessment should be used. This entails taking a history with emphasis on lesion(s) of concern focusing on: how long the lesion has been present; time course if it has changed; type of change; and associated symptoms (tender, itch, bleeding). Examination should be undertaken with good lighting and with magnification, and with the aid of a dermatoscope (it is incumbent on the general practitioner to have acquired the knowledge and skill in the use of dermatoscopy).

The practitioner should classify the nature of the lesions, particularly common benign lesions (seborrheic keratosis, angioma, sebaceous hyperplasia). The distinction between naevus and early melanoma may be subtle. When uncertain, there should be a low threshold for referral for a second opinion or an appropriate biopsy.

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), with monitoring best performed using dermatoscopic imaging. Patients should be educated and alerted that any visible change should lead to a faster review. If a review is planned the time interval should be no more than three months.

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 to provide the pathologist with maximal tissue and allow the tumour architecture to be studied. Partial biopsy (shave, incisional) is appropriate when the lesion is very large, in a cosmetically sensitive location, or where biopsy will cause loss of function (Cancer Council Australia Melanoma Guidelines Working Party 2019). Where partial biopsy is used, the practitioner needs to be aware of the limitations of these techniques, which includes the potential for histological diagnostic errors (Cancer Council Australia Melanoma Guidelines Working Party 2019; Ng et al. 2010). A punch biopsy diagnosis that indicated a benign melanocytic lesion is not definitive and is inadequate. All biopsies must be submitted for histopathological examination by a pathologist.

If referral is considered the patient should be referred to a dermatologist, skin cancer general practitioner or surgeon who can perform the biopsy, ensuring the patient will be assessed within two weeks.

For detailed information on recommended biopsy methods refer to the Cancer Council Australia’s Clinical practice guidelines for the diagnosis and management of melanoma.

The following lesions should be referred to a specialist with experience and expertise in melanoma:

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

Patients should be enabled to make informed decisions about their choice of 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 proven melanoma 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 and pathology reports)
• results of all prior relevant investigations
• history of previously treated melanoma
• notification if an interpreter service is required
• any relevant findings from a full skin examination.

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.