Local skin multidisciplinary team meetings are run at each Trust.
The Royal Surrey local skin MDT meeting occurs immediately after the SSMDT on a Thursday morning and is combined with the LSMDTs for Surrey and Sussex and Guildford and Waverley Community Dermatology Services.
The Alliance Specialist Skin Multidisciplinary Team Meeting is hosted by the Royal Surrey and takes place on Thursday mornings 08:00 - 11:00 by Teams.
The Chair of the Alliance SSMDT meetings is currently Mazhar Ajaz. The responsibilities of the Chair include leadership of the weekly meetings, indirect governance of care of skin cancer patients in the network, reviewing and recording cases submitted for tabling only, and, jointly with the Tumour Group Chair, ensuring that the SSMDT membership and circulation list is appropriate.
Membership of the SSMDT is ultimately a Trust matter relating to job planning, scope of practice and role, and is also open to specialty trainees. However the circulation list is set and curated by the Tumour Group and SSMDT chairs. Removal of an individual from the circulation list may be carried out for reasons of non- or minimal MDT engagement, and may be carried out with notice to the group for purposes of information governance compliance.
It is the responsibility of the MDT coordinator to admit participants during each meeting. Would-be attenders who are not on the standard participant list should be drawn to the attention of the SSMDT chair before admission.
To provide specialist MDT opinions and services to the Alliance LSMDTs and ensure high quality, tailored decision-making for patients.
To record cancer data.
To develop and maintain working relationships across the Alliance.
To offer services to other patients from outside the Alliance area for interprofessional second opinions or as requested by patients.
Submission of cases to the SSMDT is by currently by PDF proforma. No cases will be accepted for discussion without the proforma. It is recognised that this is extra work for referrers, but it greatly reduces risk, improves the speed and quality of discussion, and facilitates accurate data capture.
The deadline for submission of cases for the weekly meeting is Tuesday 13:00.
Clinicians are strongly encouraged to submit clinical photographs with referrals, or otherwise make them readily available for sharing during the meeting.
In addition, the MDT coordinator receives a weeky report of all skin cancer cases. They will review this report and the associated clinical notes and pathology reports, and direct the clinician responsible to submit the case to the LSMDT or SSMDT.
As of 2021, certain cases should be submitted for tabling only and not full discussion. These are as follows:
Low risk cSCC meeting a set of criteria (see cSCC).
Premalignant melanocytic lesions
Patients who have completed secondary surgery for melanoma with wide local excision +/- sentinel lymph node biopsy, where no residual disease has been found.
Any images required by the SSMDT must be transferred by the Image Exchange Portal by at least Wednesday 12 noon for review prior to the meeting. Request forms to communal facilities, notably Guildford PET, should ensure that the images are also available on the RSCH PACS system where MDT review is likely to be required.
An additional purpose of the SSMDT meeting is to enhance individual and collective knowledge. Clinicians are encouraged to submit relevant recent literature to the group for brief discussion at the meeting and potential incorporation into Alliance guidelines. Points of note from individual case histories will also be incorporated, anonymised, into these guidelines as 'Alliance experience'.
Those with cSCC or BCC with one or more close or involved margin post excision with curative intent
Patients with high-risk or very high-risk cSCC
Patients who may be suitable for Mohs surgery
Skin cancer in patients who are immunocompromised
Patients who may benefit from primary RT, following a diagnostic biopsy
Patients who may benefit from adjuvant RT following surgery with curative intent
Patients with metastatic NMSC suspected/diagnosed at presentation or on follow-up
Patients who may benefit from SACT or other oncological intervention
Skin cancer associated with a genetic syndrome.
Patients with a rare skin cancer such as MCC, AFX and PDS
Skin cancer where the pathological diagnosis requires a second opinion from a specialist dermatopathologist
Patients who may be eligible for entry into clinical trials
Those with specific challenging management issues
Completely excised BCC with 1mm or more histological clearance at all surgical margins, following excision with curative intent.
Diagnostics biopsies of BCC
Diagnostic biopsies of cSCC
A patient with completely excised low risk pT1 cSCC in a low risk patient (these can be tabled for inclusion in cancer registries where that is the local mechanism)
In situ melanocytic lesions and PT1a malignant melanomas
All SCCs. Low risk completely excised SCC in an immunocompetent pt can be tabled and not discussed.
BCCs with one or more positive or close (<1mm) excision margins (local MDTs can decide to table these where the protocol is to offer further excision).
BCCS which are recurrent.
BCCs for consideration of Mohs following diagnostic biopsy
Skin lesions of uncertain but possible malignant nature.
Where there is a discrepancy between clinical diagnosis and histopathology report.
Cases for clinical advice who do not meet the criteria for SSMDT discussion.
Malignant Melanoma
Stage pT1b or greater
Any stage of melanoma, in patients up to 30 years of age
In transit, nodal or distant metastatic disease at presentation
Newly metastatic
Recurrent
New developments requiring MDT discussion
Cutaneous squamous cell carcinoma (cSCC)
Metastatic cSCC on presentation or recurrence
Oncology and research
Lesions which may require primary or adjuvant radiotherapy
Patients who may benefit from SACT or other oncological intervention
Any case for approved trial entry
Any case for adjuvant therapy
Specialist advice
For histology opinion from SSMDT core pathologist
Cases for clinical advice from the SSMDT.
For consideration of Mohs surgery where an SSMDT opinion is requested; not mandatory if the patient has been discussed at LSMDT
Special situations
Skin cancer in immunocompromised patients including organ transplants
Skin cancer in genetically predisposed patents, including Gorlin’s syndrome
Cutaneous lymphoma: registered, but potentialy not directly managed by the SMD Alliance
Rare skin cancers
Epidermal and appendage tumours: including but not limited to:
Merkel Cell Carcinoma
Apocrine carcinoma
Hidradenocarcinoma
Eccrine poracarcinoma
Sebaceous carcinoma
Tumours associated with Muir-Torre syndrome
Eccrine epithelioma (syringoid carcinoma)
Microcystic adnexal carcinoma
Primary adenoid cystic carcinoma
Primary mucoepidermoid carcinoma
Primary mucinous carcinoma
Digital papillary adenocarcinoma
Malignant cylindroma
Malignant spiradenoma (spiradenocarcinoma)
Malignant pilar tumour
Malignant pilomatrixoma
Neuroendocrine carcinoma
Dermal and subcutaneous tumours: including but not limited to-
Atypical fibroxanthoma (AFX) (superficial malignant fibrous histiocytoma, superficial sarcoma not otherwise specified)
Pleomorphic Dermal Sarcoma (PDS)
Dermatofibrosarcoma protuberans (DFSP)
Leimyosarcoma
Angiosarcoma
Kaposi’s sarcoma
Haemangioendothelioma
Epithelioid sarcoma
Primary cutaneous rhabdomyosarcoma
Cutaneous malignant nerve sheath tumours (including cutaneous neurofibrosarcoma and malignant schwannoma
Information submitted to the SSMDM and captured during the meeting is retained as source data on SSMDT proformas.
This information is also transcribed to the Somerset cancer database and disseminated to the constituent organisations for local databasing as required.
Local databases are multiple by multiple constituent practices and clinicians
These include an oral and maxillofacial department skin cancer database that is updated within each operating list, to allow audit of marginal clearance and complications.
The RSH OMFS department maintains a skin cancer SOP.
In collaboration with the site-specific oncologists, the lead Oncology pharmacist a St Luke's Cancer Centre maintains protocols for:
Systemic Anti-Cancer Therapy drug protocols.
Systemic Anti-Cancer Therapy treatment algorithms for early and advanced melanoma.
Management of adverse effects, including immunotherapy toxicity.
General practitioners must refer patients with suspected melanoma, cutaneous lymphoma and cutaneous squamous cell carcinoma under the National Cancer Two Week Rule (TWR).
A common referral form for CCGs across the alliance was approved in 2017. It is expected that this will be updated under the Integrated Care Partnership framework.
General practitioners must refer patients with a suspected BCC to secondary care for assessment and management. As per NICE guidance, these should not routinely be referred under a TWR pathway unless rapidly growing or arising in anatomically sensitive areas and likely to impact on functional outcome.
Patients should be seen within 2 weeks of a TWR referral. Suspected melanoma and cSCC and rarer tumours including Merkel Cell Carcinoma (MCC) should be referred under the TWR as should all suspicious lesions in the immunocompromised.
The group recommends that lesions thought to be skin cancers including invasive squamous cell carcinoma, basal cell carcinoma and melanoma should not be biopsied in Primary Care. High risk Basal Cell Carcinoma should not be managed in Primary Care. This includes all BCCs on or above the clavicle.
Where skin cancer services are provided by a GP outside secondary care, this should be in accordance with current governance structures.
Lesions not thought to be SCC, cutaneous lymphoma, BCC or melanoma in origin and biopsied or excised in Primary Care that prove to be invasive cutaneous lymphoma, SCC, BCC or melanoma or other rarer skin cancer should all be discussed at the MDT and referred where required urgently under the TWR.
Cancer services should identify all GP pathology reports with a diagnosis of skin cancer as these all require MDT involvement and forward these to the MDT Chair(s) for tabling and or and action.
These patients will be dealt with by the LSMDT initially with onward referral to the Alliance SSMDT, or sometimes directly to tertiary/ joint service.
When a skin cancer has been operated by a GP in primary care who is not acting as a recognised Community Skin Cancer Practioner, the MDT Chair will write a standard letter advising them of standard pathways and asking for a referral into secondary care where further treatment is needed. The MDT coordinator will maintain a record of these patients and ensure a hospital appointment has been offered.
TWR consultations may be remote by video consultation, remote with photography or face to face
Patients will:
be reassured if clinically and/or histologically benign;
undergo photography with or without dermoscopic images of lesion(s) for recording and for good governance;
undergo thorough examination including assessment of loco-regional lymph node status where appropriate;
undergo excisional (and rarely incisional/punch) biopsy of suspicious skin lesions (if necessary and not previously undertaken); and
undergo a full body skin check by a healthcare profession trained dermoscopic assessment, with clinical lymph node assessment, if melanoma is diagnosed.
The visit will be fully documented using an agreed proforma. The ASPH skin cancer clinic questionnaire and proforma can be used across the Alliance.
Referral from between LSMDT and SSMDT members should occur in tandem or as soon as possible after SSMDT discussion. Documentation must include a completed MDM proforma, histopathology and imaging reports if out-of-Trust, and clinical photography. There is an intention for the MDM proforma to act in itself as a referral letter in future in order to accelerate patient pathways.