2.2 Assessments by the general practitioner

2.2 Assessments by the general practitioner

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.

If melanoma is suspected, a biopsy or excision should be done within two weeks of the initial general practitioner consult, and results should be provided to the patient within one week of the biopsy.