Skin cancers - recognition and referral
Exam Tips
- In UK exams, know referral thresholds exactly: melanoma suspicion (7-point score >= 3 or suspicious dermoscopy) -> 2-week suspected cancer pathway.
- Nodular melanoma may be non-pigmented: a rapidly growing pink/firm nodule can still be melanoma.
- SCC is usually considered for 2-week referral; BCC is usually routine unless site/size makes delay risky.
- Definitive diagnosis is histological (usually specialist excision biopsy), not by visual inspection alone.
- Safety point: avoid destructive primary-care treatment of lesions when melanoma is a possibility.
- Image practice is high yield: see dermoscopy and lesion morphology atlases (for example, pigmented lesion pattern figures in dermatology revision texts).
Definition
Skin cancer recognition and referral in UK primary care focuses on identifying lesions suspicious for melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC), then triaging to the correct urgency pathway. It is a risk-stratification process rather than definitive diagnosis in general practice, because histological confirmation is usually made after specialist excision biopsy.
Pathophysiology
Most skin cancers arise from cumulative ultraviolet (UV) DNA damage causing stepwise mutations in epidermal cells. Melanoma develops from malignant transformation of melanocytes (often with radial then vertical growth and metastatic potential), SCC from keratinocytes with invasive behavior linked to actinic damage, and BCC from basal epidermal cells with predominantly local invasion and very low metastatic risk. Tumour biology drives referral urgency: melanoma and SCC have greater nodal/distant spread potential than typical BCC.
Risk Factors
- High cumulative or intermittent intense UV exposure (sunlight or tanning devices)
- Fair skin phenotype (easily burns, freckles, lighter hair/eyes)
- Increasing age (especially for keratinocyte cancers)
- Previous skin cancer or actinic keratoses
- Immunosuppression (for example post-transplant, long-term immunosuppressants)
- Large number of melanocytic naevi or atypical naevi
- Family history of melanoma
- Non-healing chronic sun-exposed lesions
Clinical Features
Symptoms
- Change in a pigmented lesion (size, shape, colour)
- New or evolving lesion that does not settle
- Bleeding, crusting, oozing, or ulceration
- Itch, pain, or altered sensation in a lesion
- Persistent non-healing sore on sun-exposed skin
Signs
- Weighted 7-point checklist score >= 3 in a pigmented lesion (major: change in size, irregular shape, irregular colour; minor: diameter >= 7 mm, inflammation, oozing, change in sensation)
- Lesion suspicious of nodular melanoma (can be pigmented or non-pigmented)
- Dermoscopy pattern concerning for melanoma
- SCC features: raised, indurated, keratotic/crusted or ulcerated lesion
- BCC features: pearly/waxy nodule, ulcer with rolled edge, fine telangiectatic vessels
Investigations
Management
Lifestyle Modifications
- Give clear safety-net advice: report rapid change, bleeding, or non-healing lesions promptly
- Advise UV risk reduction (shade, protective clothing, broad-spectrum SPF use, avoid artificial UV tanning)
- Explain referral urgency and ensure referral is sent within 1 working day once decision is made
- Use local follow-up systems for missed appointments to reduce delayed diagnosis
Surgical / Interventional
- Suspected melanoma: urgent suspected cancer pathway referral (seen within 2 weeks), then specialist excision biopsy
- Suspected SCC: consider suspected cancer pathway referral (within 2 weeks)
- Suspected BCC: routine referral; use 2-week suspected cancer pathway only if delay could significantly affect outcome (e. g, high-risk site or large lesion)
- Do not attempt destructive treatment (e. g, cryotherapy/curettage) for a lesion suspicious of melanoma before histological diagnosis
Complications
- Regional lymph node spread (especially melanoma, high-risk SCC)
- Distant metastases (melanoma > SCC >> BCC)
- Local tissue destruction and disfigurement (notably neglected BCC/SCC)
- Need for more extensive surgery if diagnosis is delayed
- Psychological morbidity related to cancer concern/diagnosis
Prognosis
In UK data, melanoma 5-year survival is about 90%, while death from cutaneous SCC is uncommon and death from BCC is exceptionally rare. Earlier recognition mainly improves outcomes by reducing treatment extent and lowering risk of advanced disease at presentation.
Sources & References
✅NICE Guidelines(1)
- Skin cancers - recognition and referral[overview]
📖Textbook References(4)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 115)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1013)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 718)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 276)[context]