National Institute for Health and Care Excellence melanoma guidelines: good news for patients but challenging to implement

The U.K. National Health Service is a public-funded healthcare system. In 1999 the government established the National Institute for Health and Care Excellence (NICE) with an aim to improve clinical outcomes by ensuring that evidence-based clinical practice and cost-effective treatments would be made available on the National Health Service in England and Wales. One of the ways in which NICE does this is by the publication and implementation of evidence-based guidelines in important clinical areas. The scope of a NICE guideline is agreed after consultation with key stakeholders, and should reflect areas where clinicians feel that there is a need for clear evidence-based guidance. The development of NICE guidelines is coordinated by NICE technology appraisal teams working with a guideline development group, which includes broad representation from providers and patients in the relevant clinical area. There is a formal recruitment process to a guideline development group.

In 2015 NICE published Melanoma: Assessment and Management (NG14), a guidance document for all healthcare professionals involved in the diagnosis and management of patients with melanoma.1 The guideline development group for this topic included lay and patient members and healthcare professionals representing the skin cancer multidisciplinary team. The scope of the guideline meant that the guideline development group was required to consider evidence and make recommendations for clinical practice relating to a mix of the straightforward, the controversial and the difficult to implement. This editorial considers issues relating to a number of the recommendations and looks at the challenges of their implementation in everyday National Health Service clinical practice.

The most straightforward of the recommendations relating to patient information and support is common sense. Patients need to have access to the right type of information, tailored to need, at different points of their journey. Access, and rapid reaccess, to suitably trained clinical nurse specialists to support patients is key to this recommendation. There is widespread acknowledgement of the importance of the skin cancer clinical nurse specialist role, but where resources are constrained it is important to retain and develop these key members of the skin cancer multidisciplinary team. With regard to the recommendation around access to psychological support, most skin cancer specialist nurses have some training in this area, but further upskilling may be needed to improve access to this type of care. A significant expansion of psychology support is unlikely to occur. The use of a holistic needs assessment tool to assess the physical and psychosocial needs of patients at different stages in the treatment pathway should help to ensure that needs are met. The availability of Health and Wellbeing events for all newly diagnosed patients with cancer from April 2016 in England and Wales may help to meet this recommendation.

There is overwhelming evidence that the dermoscopic assessment of pigmented skin lesions by suitably trained individuals improves the diagnosis of melanoma and reduces the number of unnecessary excisions of benign pigmented lesions. A recommendation that ensures this happens is good for patients and good for the National Health Service in terms of resource utilization. Pigmented lesions are seen by a range of healthcare professionals including dermatologists, primary-care physicians, clinical nurse specialists, plastic surgeons and head and neck surgeons. Of all the specialisms, only dermatology specialist training requires dermoscopy as a core skill. British dermatology specialist nurses have also agreed competencies in this area. There will need to be a significant change in training requirements, underpinned by extensive clinical exposure, for those specialisms involved in assessing pigmented skin lesions where dermoscopy is not a core element of training. Good courses are available, but few include workplace-based learning and competency-based assessment.

Another way to avoid unnecessary surgical removal of pigmented lesions and to provide patients with reassurance in specialist settings is to take photographs (including dermoscopic images) and to review atypical melanocytic lesions that are not felt to require excision at first presentation. Herein are some challenges. The recommendation requires the busy clinician in the rapid-access skin cancer diagnosis clinic to stop to take photographs. What will this involve? The patient must give consent, and the camera must be positioned, the photographs taken and the images stored on a secure server at a site readily accessible to the clinician when the patient attends for a review appointment 3 months later. Departments are already giving consideration to suitable equipment, who will take the photographs and where the images might be stored. The opportunity to link to the National Health Service radiology storage system would enable the images, like radiographs, to be readily available should the patient relocate.

The recommendation that specialists measure vitamin D levels at diagnosis in secondary care in all people with melanoma sounds straightforward, and indeed arranging the blood test is the easy part. The more difficult part of this is to ensure that the result is acted upon according to local protocols and guidelines. The latter will vary around the country. Nevertheless, auditing the implementation of this should be easy. Was the blood test done? Was the result communicated to the general practitioner and was any required supplementation implemented? Following on from such an audit, say 12 months after guideline implementation, clarification of best practice to implement this within a local health community should be straightforward.

The most controversial and difficult recommendations relate to the ongoing debate around the role of sentinel lymph node biopsy in patients presenting with melanoma. The guideline development group reviewed carefully the available evidence and heard expert views from protagonists and antagonists. The first of two recommendations is straightforward, in that the evidence suggests that sentinel lymph node biopsy should not be offered to people who have stage IA melanoma or stage IB melanoma with a Breslow thickness ≤ 1 mm. The recommendation around offering sentinel lymph node biopsy to people with stage IB–IIC melanoma with a Breslow thickness > 1 mm, as a staging procedure that might give the patient and doctor better prognostic information, will be more difficult to implement. This is for two reasons. The first relates to the time required to give detailed information to patients to enable them to decide about the procedure, and the second is the variable availability of sentinel lymph node biopsy in England and Wales. The provision of written and verbal information about the possible advantages and disadvantages of the procedure is helped by tables within the guideline and by the publication of option grids in the Dartmouth style. Despite this, the healthcare professionals speaking to patients and informing shared decision making are likely to be influenced by whether or not sentinel lymph node biopsy is available locally. Large parts of England and Wales have no access to a sentinel lymph node biopsy service, and patients are disadvantaged as a result. If patients choose to have the procedure they will be required to travel long distances, and referral pathways are such that this can delay their wide local excision and treatment. For the guideline to be implemented effectively there is an urgent need for commissioners to establish sentinel lymph node biopsy services across the country to ensure equity of access. Training, support and additional consultation time are needed for healthcare professionals involved in counselling patients about the pros and cons of the procedure.

So, in summary, the melanoma guideline published in July 2015 provides evidence-based guidance that seeks to advise healthcare professionals of the clinical best practice and to improve the care and outcomes for patients with melanoma. The implementation of some of the guidelines will be straightforward, but others will be more challenging, particularly in relation to sentinel lymph node biopsy, but commissioners and providers of melanoma services in England and Wales should respond to the challenges of the guidance in order to benefit patient care.

Conflicts of interest

None declared.