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Rural Health Webinar Series - Running a Rural Skin Service – How to be Safe and Effective

Running a Rural Skin Service – How to be Safe and Effective
 
 
Dimitri:
 
Good evening everyone, and welcome to the latest instalment of our Rural Health webinar series. My name is Dimitri, and I will be hosting tonight’s webinar. So, this webinar will explore the unique challenges of running a rural skin service. A range of techniques will be discussed to identify and manage common skin conditions in a rural practice setting. Tonight’s webinar is facilitated by Adjunct Associate Professor, Jeremy Hudson, Chair of Dermatology Specific Interest Group. Professor Hudson is a Senior Lecturer in Skin Cancer Medicine and Surgery for James Cook University, and Clinical Director of North Queensland Skin Centre, a research-based clinic in Townsville. He has spent most of his career as a rural and remote GP, before specialising in skin cancer.
 
I would like to begin tonight’s webinar by acknowledging the traditional owners of the lands that we are coming together from, and the lands on which this event is being broadcast. I would like to pay our respects to the Elders past and present, and would also like to acknowledge any Aboriginal or Torres Strait Islander people who have joined us this evening.
 
Now, before we start, a few housekeeping things to go over. Participants are set on mute to ensure that the webinar is not disrupted by any background noise. But of course, we do encourage you to use the chat functions or the Q and A function to ask questions. When using the chat function, we do ask that you address your questions and comments to all panellists and attendees, rather than just the panellists, so that everyone has the opportunity to see your questions and your comments. And finally, the webinar has been accredited for one hour of CPD educational activities. To be eligible, you must be present for the duration of the webinar. We would also kindly ask you to complete the short evaluation at the end of the webinar. This should only take a few minutes to complete, and will help us to improve the format and content for future webinars. By the end of this webinar, you will be able to identify the unique challenges GPs experience with rural skin services, identify a range of resources for effective dermatological care in rural settings, and apply a range of techniques available to identify and manage common skin conditions, including malignancy. But for now, I will hand it over to our facilitator for this evening, Adjunct Associate Professor, Jeremy Hudson.
 
 
Dr Jeremy Hudson:
 
Well, hi, everyone. Now lucky you, you get to listen to my husky contralto voice, because I am losing it, so you might have to turn up your volume a bit. But thank you very much for your patience and as well, coming for a second night due to the technical issues. I think we should be giving you, you know, a generous two CPD points for tonight, seeing as you have turned up twice. As well, of course while these slides are of course the property of RACGP, I am absolutely happy for you to screen shot, use any resources you have, because this is all about benefitting you guys.
 
Right, so, because I am losing my voice, I am not going to go on as much as I was planning to, which means you might have time for more questions at the end. I have been a rural GP most of my life, and that is where I was introduced to skin. I had zero interest in it until I was out in Cape York, seeing jackaroos and cowboys with lots of skin things that I did not know what I was looking at. And you know, eventually you get married, you settle down and have kids, and currently I am based in Townsville.
 
Here is a typical rural GP and his GP wife with their kids, having Sunday lunch, as you would be well aware, it is a very nice lifestyle, isn’t it?
 
Australia is very interesting in terms of its rural distribution of resources, and I do not really need to explain to you guys the situation. I was actually just on a media hook-up before this, talking to a rural newsagency talking about the need for more rural GPs and funding and support. The statistics are kind of interesting, because we know that a lot of doctors tend to focus themselves around urban areas. We do rural because we love it. We love the challenge, we work double the hours that urban GPs do. Very time poor. About maybe 7% of dermatologists are going to work outside of an urban centre. Maybe about 7% are going to privately bill, and the majority do cosmetics. So, skin is a GP concern. Thirty-nine thousand GPs compared to about 800 dermatologists. Now, this is something that we have been doing exceptionally well for decades.
 
Joseph Collings was a Queensland MP, who actually reviewed rural health. He looked at the UK model. And what he said back then is pretty true today, which is there are not truly when you are out bush, any standards apart from your own. And there is a huge breadth of practice to what you do. And this is what we need to recognise in this education and standards, is that everyone does things a bit differently. Everyone has a specialisation, what they are good at. And part of the importance is understanding your own limitations and how you fit into the greater referral pathway. What you can achieve, what your colleagues can achieve as a team.
 
We are really entering interesting, interesting time in the last year in terms of general practice and dermatology. We have had a really big overhaul, look at scope of practice, we are just in the process of doing post fellowship recognition in dermatology, we are still interested in a couple of people if you want to volunteer to put yourself through this. It should be done by the second half of this year. There have been vast improvements technology wise, cameras, videos, artificial intelligence, treatment types. And these are things that you can take advantage of as well. There is going to be a huge, huge increase in skin cancer cases by 2030, mostly driven by gen X aging, and we all know, 48% of GPs are going to be retiring by 2030, and 14% are now becoming GPs rather than 44%. So, the onus is going to be on you guys. The great news is, this is really recognised by the government now and peak bodies, with a State of the Nation Report into melanoma. So, it essentially said GPs currently carry the burden. We treat 77% of all melanomas and far more non-melanoma cancers, and support is needed. They have officially finally said that thank goodness. So let us see what pans out with the funding. Yes, ignore what I said about decline of bulk billing, because obviously that is all going to get fixed with that 2.2 billion thing, right? Let’s see.
 
And the most important thing is, general practice is now really owning what it does. We are not dermatologists. We do skin cancer in the context of who we are and what we do. GPs are far better than dermatologists at prescribing roaccutane, because we are contraceptive experts. We diagnose more skin cancers than all dermatologists in Australia, just in Queensland and New South Wales alone. We have better surgical margins and clearances overall than plastic surgeons, and if you look at most world experts who are out there talking, many of them, like Cliff Rosendahl, they are GPs. So you can be proud about owning this.
 
Now, what are the current expected standards? Because we have just gone over this with RACGP to kind of review it. Now, what I would say is, look, if you are doing a skin check, you have got to be using a dermatoscope. There is absolutely no defence to not be doing this. You will miss half the things if you are not using a dermatoscope. Every practice should have a dermatoscope, the practice owner should buy it if you do not have one. Funding went out several years ago that practices could buy their own dermatoscope, so ask where it is. You should have basic diagnostic and management procedures that we are going to go through, that is punches and shaves, curettes, ellipses, cryotherapy and also closing things. And also as I said, understanding where you fit inside your own referral pathway. Know your limitations. And sometimes, you have to learn that by pushing the boundaries slightly, but you do it in a mentored way, hopefully a safe way.
 
Where are you going to get to post fellowship? Well, as we all know, after we fellow, five years after fellowing, we tend to pick up our own specific interest, which is why RACGP now has specific interests. In dermatology, I would be expecting five years after if you are doing skin, your number needed to treat is going to be going up. There are free resources like the SCARD database that you can use, or even pathology companies will log in numbers needed to treat for free. Things like Sullivan and Nicolaides will. You just put in if you suspect it is a melanoma, and they will come up with your accuracy rate and where it is on the body, and you get CPD points for that. Australian GPs in general will be finding about 1-2 melanomas a year and they will be probably cutting out about 30 things to find a melanoma. Sometimes 40 if they are not too flash at it. A European dermatologist cuts out 30, so pretty equivalent, 20 if they are really good, and if you are a GP who does a lot of skin, you will probably be cutting out somewhere before 4 and 10 to find a melanoma. Do not get too hung up about that being a competition. Look, if you are cutting out two things to find one melanoma, you are only finding the obvious melanoma, you are not cutting out the subtle ones. Enough of that segue.
 
Eventually, you will get onto flaps and grafts and working in high risk areas. You may know how to do gene testing, which is now becoming more available with public health, and then there are a plethora of resources for you, and this is probably the most useful thing. You are time poor, your head is full of all sorts of things. I do a lot of skin, so I am not having to deal with fractures and tractor injuries at the moment. The most useful thing for you is where to find a quick resource, and we will go through a bunch of these useful resources, supports, software, calculators, that are all for free. And as I said finally, you will eventually know where you sit, and mentorship with us is always very, very important. Never, ever, ever by afraid to call a friend, including me. We are all here to support and learn from each other.
 
Right. Now, dermatoscope. Let us start at absolute basics. Ideally a dermatoscope telehealth would be great. What do I mean by telehealth? Well, you can have a smart phone that you literally point down the lens of the dermatoscope and take a photo. You do not need a magnetic attachment or anything. That is pretty good for dermascopic pictures clinically. Know your legal obligations, i.e. delete the photo after you have taken it and sent it. And then there are more advanced telehealth capabilities as well. You should be doing a head to toe check. Never, ever, ever do a skin check without doing head to toe. Look in the scalp. Look around the lips, the eyes, between the fingers, toenails. Tell them that you do not mind looking underneath the underwear, but they need to be self-checking, because the occasional melanoma sneaks up there. Two young women in Queensland died of melanoma between the toes in the last month, one 19 and one 26, just because no one looks. Always have a protocol for consent and record your consent, because it is an intimate examination, because you are seeing someone in their undies. If you get the one in 10 thousand patients who wants to sue you, if you have every patient note saying consent offered, that will stand up pretty well medicolegally.
 
How many people have I had to have a chaperone for in my career? One. Most do not mind. Most people are pretty sensible and if you cannot arrange it, just say, come back another time ideally. Room set up. Again, ideally, curtain to get changed behind, sheet or gown, to offer chaperone, good lighting, you can actually install fluoro bulbs in the roof that are the same wavelength as daylight. Daylight wavelength. It is like a normal fluoro bulb that does not have the specific coating on it. It just is just as expensive, it is cheap. Get your practice manager to put that in. You might want some biopsy equipment at hand and things like alcohol wipes and make up remover.
 
Dermatoscopes. What are you going to get? Okay. The basic nuts of a dermatoscope is it magnifies. It illuminates and it has a polarising filter, that is like wearing polarised sunnies looking at fish under the water. It means you do not get the reflection of the light. So, a basic model would be a polarising dermatoscope. The quickest ones to use are non-contact. So you can hold it over the skin, drift around, look, look, look, look, look. Some of them have this tiny little spacer on the end which just holds it off the skin the appropriate focal length. The contact ones are the ones that have a lens that you smash the lens right against. Some are combination.
 
Why do you want contact? And why do you want non-polarising? It is because if you get some gel, like some alcohol hand gel, great stuff you know, it sterilises the patient, you put it on the lesion, you put on your contact dermatoscope, you switch off the polarising mode so it is non-polarising, you see surface features better. And when you get good at dermoscopy, you will find clues to malignancy like white lines and stuff like that. So, that is why they have the additional bells and whistles, but minimum polarising non-contact is a nice cheap option. You probably have to be spending in the realms of $800 at a conference on special to get a decent model. Little ones like the DL 100 in the bottom left, I would not recommend, not recommend at all. You can now get attachments for your phone and stuff as well that are pretty cheap.
 
Right. But look, they mastered the dermatoscope a long time ago. All the stuff about pigment boost and 30 extra LEDs and stuff, do not believe a word of it. It generally looks a little bit nicer, but it is not going to make or break anything. And if you can, get them to send you one to try, because if you have an eye condition like a slight astigmatism, it may look a bit wonky on some people, so always try before you buy ideally. And they will send them to you for free, generally to try out.
 
Now, just a heads up, there is a grant that just came out for digital health accreditation. You could foreseeably up your telehealth with this. Alright, so you can grants for 25 to 50 grand through the government. So if you do not have any good telehealth, you could potentially get yourself a nice dermatoscope and some telehealth capabilities by doing this. So just be aware, that is out for a short time. You can take a photo of that if you want.
 
Okay, let’s move on to sampling. So we are going to pretty kind of rapid fire high value and go through a bunch of stuff. If you want to get into the in-depth stuff, we have courses, we have lectures later in the year. So, we are going to talk about sampling. Punching, shaving, curette and excision. Know what is good for what. Punches are for keratinocytic cancers. That is the new name for the non-melanoma cancers. So, basal cell, squamous cell, both come from keratinous sites, they are called keratinocytic cancers. Try to punch the full way through one of these because you will often find high risk features at the base, like infiltrating BCC at the base of the BCC. You can also do inflammatory conditions. You may want to get a border of normal skin and abnormal skin. But absolutely try your best and never partially sample a suspected melanoma. So, if you have a suspected melanoma, always make sure you are looking at the whole thing, because sometimes some of it is pink if it has regressed. If you partially sample a melanoma, you will lose the diagnosis 25% of the time.
 
Shave, again is quick and easy to take things off. I tend to personally shave a lot of shallow melanomas. You need to know what you are looking at. There was a study done by Blake O’Brien, a pathologist last year, that showed it is operated dependent. If you shave nicely down to the dermis, the dermis is where you can see the pin point bleeding, you should be pretty good. And look at your report. If your segmenting nevi, or your segmenting melanomas, do not do it, you are not good enough at it. Or sorry, I should say, you are not doing it properly. Okay? And you do not want to segment a melanoma because it mixes up the depth, the Breslow thickness which guides treatment. Even you take more out, the granulation tissue is going to muck that up for you.
 
Curetting is when you rip something apart with a curette. Usually warts and lower risk BCCs when that is combined with cryo. Not hyfrecation, cryo is much more reproducible that hyfrecation. For a lower risk BCC, I would say a BCC less than 10 mm, arm, leg or trunk, is appropriate for curetting and cryo, that is low risk.
 
And then excisions. Keratinocytic cancers, melanomas, blistering lesions. Excision is the best gold standard if you can get to it. For diagnosis, you do it with a 2 mm margin unless you are sure of what it is.
 
Now, danger zone. Danger zone, danger zone. Take a photo of this. Take a screen shot. Do not operate above these spots, unless you know what you are doing or you have had some mentorship or training. Most of these are around the head and the neck. The ones with the little stars next to them I have put down, have arteries, or sorry vessels, that travel with them.  The most commonly damaged one is the temporal branch of the facial nerve. There are a few other spots as well. There is the Erb’s point on the lower neck, which also has sensory nerves above and below it, but it is very predictable where a lot of these things run if you know what you are doing. Temporal artery, be careful. And then dorsum of the hand, very thin skin with lots of structures. That is where some people run into legal problems if they go too deep. One thing that I did not put in but might mention is the head of the fibula too, where I believe it is the peroneal runs that can cause foot drop if you hit that. So be careful with that as well. And there are courses you can do or resources online, I think I might have some lectures online with RACGP already that you can look at.
 
Right, punch biopsy. It is a trephine, circular, razor sharp, goes straight down. Lots of different sizes. They are for free, fantastic. Now, 2 mm. I never, ever use a 2 mm unless it is on an eyelid margin. Again, know what you are doing, because a 2 mm punch an eyelid margin, you do not have to suture it.  However it is a miniscule amount of tissue. It is good for confirming cancer. Why I say that is, because if you do a 2 mm of a punch of a suspected BCC to the eyelid, it comes back as not BCC, you are obliged to take a second punch to double check, because you have not provided enough specimen. A lot of people use 3 mm. I use 4 mm because you get about you know, pi R squared, you get about 46 or 48% more material going from 3 to 4 mm. 5 to 10 mm, look, it is quite often good. You can remove small pigmented lesions with a 1 or 2 mm margin in total and suture that. That is an excision. An excision using the punch biopsy. Okay? You bill it as an excision.
 
There was a trial done double blinded, actually, talking about suturing these things, and at least on the limbs, you can go up pretty high like 6 mm, perhaps even 8 mm sometimes. And there is absolutely no difference to the scar afterwards if you have sutured it or not. They double blinded it, which was interesting. So patients thought the scar was better if it was sutured. But if everyone just looked randomly, there was no difference. So sometimes you can just dress it with a bit of Melolin or Algisite.
 
How do you do it? You stretch the skin, you see those little lines are the skin tension lines. You do a swivelling motion. You are very careful you do not go down through to the tendons. And then you can put in a deep dissolving suture, you can put in a purse-string suture. Now, if there are structures underneath you are worried about, A) you can inject a bolus of anaesthetic. Put in a ml or two. Or even saline. Push it up above those fixed vessels and tendons and nerves. Alright? So you have a buffer of safety. Or 2), you pinch the skin and you lift it up. And when you cut this out and after stretching the skin, you will actually see where the skin tension lines go and how to close it.
 
Shave biopsy. Just a scalpel or a disposable shave. A shave biopsy, you go through the dermis. It takes a couple of weeks to heal. Be careful with elderly folk below the knee, it can take a month or two months to heal if you are not careful. Keep it covered. It heals pretty well, but you do get a pale patch, because you take out the tan. If you go deeper down, you start hitting the subcutaneous fat, that is a saucerisation, you get more scarring. Takes longer, but it is a legitimate way to take something out. Generally only for suspected shallow lesions. You know, IEC, BCC types of things. And again, maybe do consider if you really do need to shave a suspected melanoma, there is a concern they might over-diagnose melanomas by shaving them, but oh well.
 
Now, topical haemostasis. How do you stop bleeding? Get yourself some aluminium chloride. You can order it online. It is an antiperspirant. It has been used for hundreds of years in the Middle East and it is called an Alum block. With shaving, I will show you what you do. You just rub it on. Rub it on firmly for about 10 to 20 seconds it stops the bleeding beautifully. If you use too much of it, it can interfere with the granulation tissue healing. 20%, it is an ethanol, 70%, so it is flammable, so do not be hyfrecating it immediately after using it or you will set it on fire. There are other things you can use. So, some people use, just out of my mind, it is the tablet that women take for heavy periods. Sorry, that will come back to me. You can dilute that in water, to use that as a haemostatic agent. If someone is on platelet inhibitors, or they have platelet issues, 5% hydrogen peroxide is good for stopping bleeding. You hold it on the swab for 30 seconds, but you do have to rinse the wound out if you use hydrogen peroxide. And there is other stuff like ferrous fumarate and stuff, silver nitrate, but that stains the skin. So aluminium chloride or Driclor 20% is good. And yes, you can order it online or get a compounding chemist to put it together for you. Cheap stuff, works well.
 
Next. Okay, curettes. Obviously because you destroy something with a curette, you cannot tell what the margins are. You always look at the report and if there is evidence of infiltrative components, you may consider then cutting it out. You get two flavours. You get the silver ones which are sterilisable that are blunt. You get the green ones that are sharp. Now, why are the silver ones useful? Because they do not go through the dermis. So, if you have a superficial BCC, you stretch the skin, you curette it from multiple angles, while paying particular attention to the edges, because that it is where these tend to recur. You will know that you get down to the dermis, because you see the pin point bleeding, and it will stop going through and it will make a very rough sound like grr, grrr, because you have hit the fibrous tissue. You got the dermis. Great. You have gone through the BCC, perfect. The green one will go through to the lino floor if you keep going, so be aware of that. They are better for warts and hard things, and removing the tops of AKs before you treat them.
 
Now, excision. Remove 2 mm margin for diagnosis. If you know it is a melanoma and you go, I am 100% sure that is a melanoma, still do a 2 mm margin. Why? Because if you need to do a sentinel lymph node biopsy, you need the local tissue intact. So it is always a two-step process for suspected melanoma. And they came out with these new codes that I have been just debating with the dermatology advisory group, where now if you suspect it is a melanoma, and you cut it out, you can bill it immediately without histological confirmation as a new suspected melanoma code, and that is why they introduced those, so you do not have to wait for the billing to come back. When you are actually marking this out, you put a dotted line around the edge of the lesion. You put your dermatoscope on it to make sure that the edges are all in there and you modify it if not. You then put your curative margin as a solid line outside that, that is your defect that you bill Medicare. And then you make your ellipse to close it. And the ellipse, you know, dog ears, are not included in the defect size.
 
And I had a chap come in this morning, quite conveniently, just a bit of a clinical case for you. So this is on the lower leg. Old fella, thin skin. And I remember being a rural GP and having absolute brown pants time, spending 2.5 hours trying to close something on the lower leg, when I had bitten off more than I could chew. What you need to do is plan your get out of jail free cards. So look at the left-most image. This is a suspected SCC, I am giving it a 4 mm margin. I have tested the skin to see which way it goes, which is why I have drawn the straight line. So, now, first thing you do, you do about three or four to one ratio, with the width of the defect to the length. That is what I have done in number two. But from my experience, I know that that is not going to close it. So, what do you do if that is not closing? Well, easy, you extend the ellipse. You make the ellipse much longer and then you work your way from the outsides in. So that is what you do if you have to get a get out of jail free card. Another get out jail free card, what is your next step? You undermine more. You undermine generously to about the width of the excision around. That always helps. Always undermine more. Blunt dissection is usually best. You stick in the scissors and you open them so you do not tear blood vessels. What is your next get out of jail free card? Let’s see, I have done this lovely long ellipse and it is still not closing. Well, here is a few more little tips, might be a few more advanced, okay? This is a parallel cut. So you measure the width of the excision, you measure that off to the side, you come out at 90 degrees, and you mirror the edge of that ellipse. And if you incise that and create an incision, and you undermine around the edges, you get a whole bunch more movement. Now technically, that is actually a bilopedicle flap and theoretically you can bill it as a flap, provided the defect is large enough. You could do a second one on the other side theoretically if you wanted, as well. Again, get out of jail free card. At any point, if you cannot close it, you can flap it or theoretically graft it, or leave it to heal by secondary intent, or you can refer on. So there is always a get out of jail free card. And this is an example.
 
This is converting it to essentially a keystone flap, where you cut out that whole rectangle and you shift it. I did not do that, I closed it primarily with an ellipse. When I started, I was probably doing about seven or eight flaps a week, doing full time skin cancer. I had a colleague who thought he was the bees knees because he does 20 to 30 a week. Now I do two a week. Because when you are really good, you figure out you do not have to flap and graft things. So you can do a lot just by knowing the basics really well. If you need to do something really basic for a flap, you should learn a workhorse flap like the rhomboid flap and go to a course or get a mentor.
 
Now, again, just some resources that I have written down for you. Margins. Because if you google this, you come up with so many different margins and you are really puzzling which ones to use, this is what I use. Margins are a bit funny, because most of these margins are written by high-risk American surgical hospitals. So, low risk BCCs as I said, 2 to 4 mm margin. Make sure it is clear on the report, or 1 mm clear if they give you a measurement. A measurement is not really mandatory. If it has got, you know, things like infiltrating or high risk, you need a good margin on that. So, remember, histological margin is different from clinical margin.
 
High risk BCCs are larger, you know, potentially even infiltrating, multiform, like nodular and superficial, 4 to 6 mm. If it is recurrent, coming back in the scar, you cut that sucker out with 6 mm margins ideally. And you remove scar tissue as well, because it infiltrates scar tissue. Or you do Mohs. Now okay, Mohs is when they do a very close margin, and they test the whole thing all around. You can do something as a GP with some pathologists called CCPDMA, closed circumferential peripheral diameter margin analysis, but they call is Mohs. Anyway, it is actually a slow Mohs, and it gets set in paraffin and you can actually very accurately take it out very closely. That is preserved for higher risks ones, poorly defined, usually on the nose or the face. And then, so know that that is something you can do, but use it tactfully, do not waste it. Ask your pathologist about the capacity for this. Do not tell them I told you about it.
 
Low risk SCCs, yes, 4 mm margin, increased risk SCCs 6 to 10 mm, and then red flags, you know, you really have got to know your red flags. This is where people get stung, poor, sometimes moderate diff, larger, deeper, fibrosing arms, lips, ears et cetera. You really need to be talking to someone else and getting a second opinion to protect yourself and be planning to do lymph node checks afterwards.
 
Melanoma margins, for those of you again who just get a little bit confused by the terminology, melanoma in situ is a melanoma in the top level of skin that is not yes invading. So, really no big risk. And eventually they go deep, they invade. Lentigo maligna, is also melanoma in situ, on the face. Okay? That is the only difference. Once you start getting above T1, above a mm, that is when you are thinking of referring for sentinel lymph node biopsy and surgery, so you typically do not do that yourself. So you should be doing about a 10 mm margin generally. Sorry, I did not put that in there, melanoma in situ at least a 5 mm margin. Okay? Clinical 5 mm margin. Lentigo maligna 10 mm margin. Why? Because the melanoma in situ on the face, lentigo maligna, has little skip lesions at the edges, they find it very difficult, it has got a high recurrence rate unless you are at least 7, 8, 9, 10 mm clinically away from the edge. That is why lentigo maligna has got a bigger facial clinical margin.
 
Recalls. You must have a practice protocol for recalls that you adhere to, and your staff adhere to. Even if they do not follow it, you can get sued, you poor bugger. So, how do you recall people with results of their routine skin checks or their lymph node checks? A good rule of thumb is two phone calls written in the notes, they did not answer the phone, one registered letter, and you have done your duty pretty darn well.
 
Lymph node checks. If I had someone with nasty lymph nodes, I would do a three month check for two years, feeling the region nodes, and then six months check for the third year.
 
Resources. Trees and grass and dirt and spiders and snakes. So, cows that eat snakes apparently, too. Cancer Council Australia is very, very good. A lot of reading, but you can drop down to the area that you need. They have got general recommendations at the end. That is for kerotinocytic cancers. Their melanoma guidelines are quite up to date. I have put cryotherapy as an example, because there has been a lot of litigation on cryo recently, people definitely not doing it properly, as in they do too much, damaging tendons and arteries. People have lost fingers, a couple of people in the last year, by people cryoing fingers for 15 minutes, 30 minutes, you know, we should look at the guidelines but we are thinking more like, 15 seconds, 20 seconds, 30 seconds type of thing. You always consent people for cryotherapy, it is one of the most litigated things as well, but I hate to go on about that. I verbally consent them.
 
Right. Again, yes, they have the melanoma guidelines as well. This is very easy to access. So if you are really fussing about a case, if you cannot talk to someone, look at these guidelines.
 
Melanoma Institute of Australia, or MIA, has a good doctors’ education portal. They have got educational resources for patients, they have got educational resources for you, they have got educational courses for nurses and your staff that they can do. Very good. Very, very, very good. I would recommend going on there and doing some of the melanoma courses or booklets on how to treat melanomas of different depths. Great bunch of people. Yes, e-books are free to download. You can download the resources, yes, like, Melanoma Essentials Concise Guide. The basics are pretty simple. Just know when you are beginning to hit the hairy stuff.
 
Now, I wanted to show you this. So, this is a risk prediction tool, and I am actually going to show you how this works. Let me just share my other screen. New share, can I do new share? There we go. Is it actually working? Can people see this? Yes, tranexamic acid. Yes, okay, anyway, can people see this melanoma risk thing? Okay, well anyway, yell out if you cannot. So, right, this is really useful, because it used to be, you send someone for a sentinel lymph node if the melanoma is more than 1 mm deep Breslow. And then they said, er, 0.8 if they have some other weird features. If anyone ever says 0.75, ignore it, because they always round up to 0.8, they are not that accurate on histology. What you do is, you get a sentinel lymph node metastasis risk. Now, this is why it is an interesting point. So, let us say I have a 27-year-old male. He has got a tumour of 0.6. Absolutely well under 0.75 or 0.8 or 1. Superficial spreading most common. A little bit of mitosis, a bit active, no lymphovascular invasion, 16% risk of metastasis. Previously, they would have said, do not bother, because this is based on 30 years of Australian data. So this will tell you really nicely whether or not they need sentinel lymph node biopsy, and this is where people would be getting caught out. Younger adults with a slightly high mitotic rate, actually have a high metastatic rate. And they will tell you down here in the bottom right, if the risk is below 5%, you tend not to recommend, but between 5 and 10 and you discuss it or you refer on for discussion, over 10, you tend to send for a sentinel lymph node biopsy. Quick and easy to do.
 
Q and A. Yes, thank you, Michelle, good to see you online. Alright, good, and there are a whole bunch of other ones there as well that you can use, like what is the risk of a first melanoma. What is the risk of a subsequent melanoma? What is the risk if it is you know, recurrent? So these are very useful. If you get someone in and you pop in their details, you can find out you know, how often they need to come back. Wonderful, wonderful stuff. Alright, let us go back to the PowerPoint.
 
Okay dokey. So melanomarisk.org.au as it is up on the top. I think I put a link to that at the end of the slide.
 
Melanoma Patients’ Association Australia. Great resource for patients. Education, other groups. Melanoma is effected by many, many different things, and skin cancer is too, so a lot of stuff about wellness and looking after yourself, legal, financial, palliative. Fantastic resource.
 
But something that is exceptionally good for rural people is the Melanoma Nurse Telehealth Service. So, I helped when this was a polit. The name was Brooke then, now I think it is Sarah or Ashleigh, the new nurse. This is a rural nurse oncologist, who your patient can ring, and they will help answer questions, organise visits, talk to family and friends, fantastic service, absolutely every patient is raving about it. If you have a patient with a melanoma, you can put them on to this.  So, Melanoma Nurse Telehealth Service.
 
Clinical trials. Look, there is a lot of new medications out there like the mRNA vaccines that are about 40% better than current immunotherapies. Even combination immunotherapies are fantastic. There are a whole bunch of clinical search databases, and I would say the two best are Melanoma Institute of Australia and then ClinTrial Refer. ClinTrial Refer is good, because you can use it for different cancers. I actually have got this changed with RACGP, so now time that you spend with a patient looking at clinical research trials for them, you can claim as your CPD. So, like, I think it is half a point per half hour or something like that. If it helps. Allow me just to quickly show you how this works as well. Okay, okay. ClinTrial Refer. It takes a bit of navigating, you can get it as an App on the phone. Patients can have it too for free. You have just got to search for trials. And let us say, I had a patient in oncology, 945 trials available, do not worry, it gets less. Health conditions, let us say melanoma, 100 trials. Let us go for metastatic melanoma, that is relevant to one of our cases. And let us go first line. Sponsor does not matter. Australia, most are in Australia. Your region, you can get travel funding a lot of the time for patients to go to different areas, but many of these are multisite now. Staff is open. So there is 16 for sort of first line metastatic. Advanced is, yes, whatever. Now a lot of these, for example RO7247669, you just have to google what that is. But the great thing is, you can go into details, it will tell you inclusion and exclusion criteria. Where are the locations and who they can get directly in touch with, email or phone, to ask if they can be on the trial, are they recruiting? Fantastic way to give patients a whole bunch of access. You would be surprised, or maybe not surprised, how many patients come back from the hospital, and none of the oncologists have mentioned clinical trials. So again, your GP role as the expert, an advocate, is to you know, help people with this sort of journey, and maybe even some of you have family members who are suffering from cancer, well, there you go.
 
Okay, where are we up to? Okay, let us talk about a case study. How are we doing for time? Oh my goodness, okay. I will get on with it then. I will rip a little bit faster through this, so we have enough time for questions, okay? So, let us say, young male, 24-year-old, presents with a lesion to the neck. Wife is concerned. What do you do? Obviously the first thing you do is you take a history. So I will try to lie out for you the gold standard of how you would approach someone with a skin check. So, what is the history? New lesion, irregular lesion on the neck of a 24-year-old, melanoma is the most common cancer in 20 and 30-year-olds. Highest cause of death, kills more than car accidents and alcohol. You know, he has not had any cancers, but he works on a cattle property, he sometimes got burned, but pretty good. Recent father, young daughter, three months old, does not smoke, does not drink, pretty healthy like most of this generation, right? But feels pretty well. Okay. Examination, let us say it looks like this. And, hopefully, you do not have to look at it to think it looks too odd. If you do not know what it is, okay, if you are looking at this and you are saying, I do not know if that is a melanoma, know your safety criteria. If it is new, changing on an adult, looks different to the rest, particularly if it is raised, you never leave a raised lesion, you either get a second opinion, or you biopsy it. You will get very, very good at your number needed to treat if you photograph everything you biopsy and look back at the end of the week. It is the quickest way to get better, and eventually, you will stop taking out seborrheic keratosis. So what are you going to do? A full skin check, head to toe. I once had a guy with seven melanomas on him in situ. In one visit. Ridiculous. Absolutely ridiculous. Put your dermatoscope on every single lesion. Melanoma is a snake in the grass, it does not really care if you are tired or over-worked. Put your camera on everything, and you will get fast at it with time.
 
Okay, next step. Let us move through. Lymph node check. I just quickly added this in. Look, generally, you do want to feel the regional nodes, but they can go many different places. When I do a full check, I tend to check behind the knee, inguinal, liver, spleen, armpit, epitrochlear, which is in front of the biceps there, and cervical. If it is a head and neck thing, especially a CSS, I do bimanual palpation of the floor of the mouth. But something like, if you have a melanoma on the back, upper back, and it spreads, like 0.6% of the time it is going to go behind the popliteal node. Like behind the knee. So crazy, it can do stuff like that. So, I tend to just get good at doing a quick check, and remember, if you feel a node that is abnormal, send them for an ultrasound, plus or minus FNA, fine needle aspiration, so they can get the procedure done then. Okay? If they need to get it done then.
 
Alright, cut it out with 2 mm margins, marked as urgent so the pathologist contacts you directly. Book in a phone appointment for three days’ time, so if he does not meet the appointment that is scheduled in, you have that recall system. What was it, 1.2 mm thick, superficial spreading melanoma, no mitosis or ulceration or lymphovascular invasion. You can quickly calculate the sentinel node risk. Let me just smash it in, 26 let’s say, 1.2 mm. You think you should need a lymph node biopsy anyway. Superficial spreading, no mitosis, no ulceration, no invasion, 12% risk of spread okay? Alright. So you counsel him, you can explain the procedure. They will probably want to stick dye in and see where it goes.
 
You have to do all the proper holistic stuff. Discuss feelings, thoughts, anxieties involve the family. He has a three-month-old daughter. Refer to the Rural Nurse Coordinator, give the resources, talk about future melanoma risk prevention, calculate his future risk of melanoma according to that scoring system. Sunscreen halves your risk. Apparently, and an occupational lawyer told me this, if you have had a skin cancer, you have worked outdoors, you can get a one-off payment from WorkCover, but I have not proven that yet. Eye checks. You can get melanomas on the back of the eye, particularly with light coloured eyes, I would say yearly or two yearly check with an optometrist. Diet is important, five to seven different veggies a day. Maybe avoid supplements, because some supplements increase your risk of cancers. Right? So N. acetyl-cysteine increases melanoma aggressiveness in mice at least 30%. Nicotinamide or B3, which we use for helping people with like sun damage and SCCs and BCCs, that increases your risk if you have triple negative breast cancer, which is about 1% of breast cancers, it makes it go wild, so you need to know a little bit about that. So, I tend to say, avoid supplements unless you are deficient, try to eat a healthy diet. Alcohol reduction every one standard drink of alcohol per day, per week, so seven drinks a week increases your risk of melanoma and skin cancer by 11%. It is a linear relationship. If you drink a six pack every day, that is a 66% chance increase risk of melanoma and skin cancer. And weight management. If they are obese, and they lose about 20% of their body weight, they get about a 70% reduction in melanoma. So, GP management plan time guys. For melanoma, you can do that.
 
Okay anyway, look. Let us breeze through this. Wide local excision by the surgeon, had a couple of positive lymph nodes in the neck, microscopic deposits. Lymph nodes dissected. He was offered immunotherapy but the patient declined. He did not say why to the oncologist. I did ring him, he said the side effects sounded too severe. He wanted to work outside and earn money for his family. We talked a bit about clinical trials, but not too interested, but sent him the email anyway. After a while, he popped back in, melanoma metastatic on the forearm. You excise these with 2 mm margins, you can do that as a GP. I cut out a whole bunch of his.
 
Next steps. If you have a recurrent melanoma, or metastatic, of course you will be thinking about PET combination CT for scanning the body, MRI for the brain. There is a bit of debate about whether you have to do that for a recurrent in situ melanoma that has come back in situ. I have talked to the two heads of the Melanoma Institute, they have both said different things, so I imagine it is take it or leave it. Discussed psychological issues and re-address clinical trials, patient accepted referral to a clinical trial. After 18 months combination immunotherapy patient is clear. Thank goodness. He looks cured at this point. But he has been getting sleepy and tired. Immunotherapy, you should know about the side effects. You know, you can google them. But in his case, you know, he was tired, so you know, it ended up being depression. We did have to screen him for some hormonal problems of course you can get after immunotherapy. Being rural, well, what else? How are you supporting your family? Where are your fire arms? Are you suicidal? What are your supports like? And he has now recovered really well and seems to be in the clear. So, hate to rush through that, but really it is just to say, that is what a GP can do as a GP. There is no way a surgeon, or a dermatologist, can do all that. And just think about how grateful these patients are for that type of treatment.
 
Gene testing. We might update this soon, but the current gene testing is for something called CDKN2A, public hospitals will test this in their genetics if the risk is over 20%. It is linked to pancreatic cancer and melanoma. So, if you have had a family with three melanomas in it, you might think of CDKN2A testing, because there is a 50% chance it gets past through the family. You test it with this testing called, sorry, it is a horrible thing to get to, genomel. You basically put in age, how many melanomas, how many in the family, and whether they are pancreatic, and you refer them on accordingly. There are private companies that do gene testing for melanoma, or all cancers, it costs about 250 bucks to 300 bucks US, and they get counselling with a gene counsellor afterwards. They do not get counselling about what gene tests they get beforehand, but surprisingly it costs the same amount to get two versus 10 versus 20 done. For your own information, the government recently made a moratorium on genetic testing, where insurance companies cannot ask about gene testing if your insurance for your life is less than 500 thousand. So be aware of that. So some people avoid it due to insurance issues. And if it is over 500 thousand, it might be that they cannot ask about family members’ gene testing, yes.
 
Okay, so do get in touch if you have any questions or are interested in joining the Dermatology Specific Interest Group. We work on national policy, curriculum and guidelines and things like the post-fellowship. Anyone of all levels, we are the biggest specific interest group in Australia. We have got about 3, 600 members. You are very welcome to always contact me like anyone, we are all colleagues. I find not many people bother me unless they have a curly one, like a toenail melanoma question. So please, please do get in touch just to support each other.
 
Now, we might just take a couple of questions while we have a few minutes left. Yes, tranexamic acid, absolutely you guys have got it dead right. I think it was, there was a letter to the editor about this, about putting one tablet in 10 litres of water to get a 5% solution that should be effective. Great. Post fellowship in dermatology, yes, so that is essentially, look, we said a lot of GPs who work more than five years actually started getting good at things they do not teach at fellowship or on the exams. And that is what we call post fellowship specialisation. There are about 30 specific interest groups. Now, dermatology was one of the first three, and now that is formally being recognised. It is not a qualification, you do not get more money, but it is at least saying, we recognise that you have put a lot of effort in. And it has allowed us to review the standards of practice that exist at fellowship and post fellowship and very importantly, what it now means is that if you go, well, I hate to say this, but before a panel and someone questions, oh, why did you do this with this patient on their lip? And you get an ear, nose and throat professor commenting, saying you were not qualified to do that. We have GPs who say no, as peers, we are completely able to tell you that what you did was correct or not. GPs you know, commenting on other GPs, which is how it should be. GP business is what we own and what we do. So yes, we probably do need a couple more people who have an interest in dermatology, to apply for this post fellowship recognition. So if you are interested, just email the GPSI email there. We want people who probably do at least 60% dermatology in their derm mix, it cannot all be skin cancer.
 
Anyway, we are nearly at the end there, so we might just take any further questions there are. Clinical examination of lymph nodes, is it necessary in all melanomas, including in situ? No, not really. You know, I was talking to someone about this the other day, because they never really spell it out. The good consensus is now, in situ, not really necessary to do lymph node checks. Anything that is at all invasive, I would do lymph node checks for at least five years after excision.
 
Any other questions?
 
Dimitri:
 
That is great. Thank you so much Jeremy for that great webinar. Very good. I have also in the chat, sort of function there, I have included the web address for the RACGP specific interest, so there is more information about sort of joining the Facebook groups as well as a lot of information on some great resources that RACGP members can access, which is great.
 
A reminder too, to also please complete the evaluation that will pop up in a moment when the webinar session closes. It really will only take a minute or two to complete. Certificates of attendance will become available on your CPD statements within the next couple of days, so just make sure that you look out for those. And for any non-RACGP members who would like a certificate of attendance, please just email the Rural Faculty, that is, rural@racgp.org.au. And of course, do not forget to tune into our other three monthly webinars, held on the first Thursday of every month. Our next webinar will be on June 2nd, I think it is, the first Thursday of June, and it will be on fresh developments on diabetes managements, and that will be presented by Dr Gary Deed. And on that note, I would like to end the webinar for everyone, so you can all have a wonderful evening, thank you and have a great night.
 
 
Dr Jeremy Hudson:
 
Thank you all for coming a second time.
 
 
Dimitri:
 
Yes, absolutely. Thank you all for your understanding and your patience. Thank you. Have a great night.

Other RACGP online events

Originally recorded:

4 May 2023

This instalment of the rural health webinar series will explore the unique challenges of running a rural skin service. The webinar will also explore a range of techniques available to identify and manage common skin conditions in a rural general practice setting.

This webinar will be facilitated by Adj A/Prof Jeremy Hudson, Chair of Dermatology SIG for RACGP. Adj A/Prof Hudson holds multiple advisory positions for dermatology standards and education. He has worked  predominantly as a rural GP for most of his career, and is currently directing a research based clinic in Townsville, the North Queensland Skin Centre.

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Learning outcomes

  1. Identify the unique challenges GPs experience with rural skin services
  2. Identify a range of resources for effective dermatological care in a rural setting
  3. Apply a range of techniques available to identify and manage common skin conditions, including malignancy

This event is part of Rural Health Webinar Series. Events in this series are:

Facilitator

Dr Jeremy Hudson
Chair, RACGP Specific Interests Dermatology

Dr Jeremy Hudson is a Senior Lecturer in Skin Cancer Medicine and Surgery for James Cook University. He is also the Clinical Director of the North Queensland Skin Centre, a research based clinic in Townsville, and has a strong interest in medical education and improving clinical guidelines. He has spent most of his career as a rural and remote GP before specialising in skin cancer.

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