I couldn’t resist the dramatic title, although, as I’ll disclose below, a less dramatic one would more accurately reflect the content of this piece. Normally a title like “I’ve got cancer” is followed by bold words about fighting my cancer all the way, never submitting, never saying die. People might call me brave. Or the title could lead to a reflection on what it will mean to die, what I will treasure and how I will spend my remaining time, probably writing a weekly or daily blog as I got closer to “that distinguished thing.” But, luckily for me, I have the most boring of cancers.
I have a basal cell carcinoma on my upper left chest, and a more accurate title to my blog would be “How I’ve contributed to overwhelming dermatology.” It’s the slowest growing of skin cancers, and I’ve had it for about two years. I guessed with the remnants of my medical education that it probably was a cancer, but I never did anything—until my daughter, an enthusiastic medical student with much greater faith in medicine than me, urged me to see my GP. I saw the GP, and after a momentary glance at my lesion he referred me.
Because of the magic word “cancer,” I had to be seen within two weeks. I could have had pancreatic cancer or a fast growing brain tumour, in which case it probably wouldn’t make much difference when I was seen as they would kill me regardless, but I might have had something where it would make a difference. The fact that I’d had my lesion for two years might have been a clue that an urgent appointment wasn’t needed, but cancer, the “emperor of all maladies” and perhaps the “second most distinguished thing,” must be respected.
All sorts of bureaucratic absurdities followed (see here), but within three weeks I arrived at the crowded dermatology clinic. The consultant took one look at me and said I had a basal cell carcinoma. I stripped off, and he cast his eye over my collection of benign skin lesions, giving me names for each of them. Most of the 15 minute consultation was spent filling in forms for me to consent for a photograph (“you won’t be in a textbook, too boring, but we might discuss you at a multidisciplinary team meeting, although probably not”) and surgery and completing a request for pathology.
The consultant, a kindly competent man, explained to me how the requirement for patients with suspected cancer to be seen within two weeks has overwhelmed dermatology. GPs, he fears, have lost their confidence when diagnosing skin lesions. A patient with a suspected basal cell carcinoma doesn’t need to be referred within two weeks, but if GPs are uncertain, which most of them seem to be, then the patients are referred. Patients with suspected squamous cell carcinomas, which do rarely spread, are supposed to be seen within two weeks. Patients with possible malignant melanomas are the ones who really need to be seen quickly.
In the average clinic the consultant and his two registrars see some 30 patients. They might see one or possibly two patients with malignant melanoma, making the clinic, the consultant said, “worthwhile.” Then there might be a few old timers like me with non-aggressive skin cancers, but most people, many of them young, have moles. “This isn’t supposed to be a mole checking clinic, but that’s what it’s become.”
Nobody is at fault. Anxiety about cancer is understandable and probably growing. Perhaps because of its close association in people’s minds with death it trumps other conditions, some of which are more lethal, leading politicians to introduce things like the two week target and the special fund for cancer drugs. People are learning more about malignant melanoma, and as moles are common it’s easy to see why people worry. GPs as a group are probably both less comfortable with skin lesions than in the past and more risk averse, so they refer more. The clinical assistants who divided their time between dermatology and general practice and used to mop up a lot of the skin problems in general practice have largely disappeared because they don’t earn enough in the hospital sessions to meet the locum cost in general practice.
The result is that dermatology, which remains hospital based, is being overwhelmed, and resources that could be much better spent promoting health outside the health system, are being spent reassuring people that their moles are benign.
The system needs to change. As the consultant said to me, dermatology should probably be based in primary care, not hospitals. There might be health workers, perhaps nurses, specially trained in dermatology based in general practices. Or maybe technology can help: pictures of the lesions might be sent to a central place, perhaps even in a low or middle income country with lower costs, where a team of dermatologists could triage referrals. Indeed, the problem of diagnosing skin cancer seems ideally suited to artificial intelligence. There’s every chance that a trained machine that continues to learn could be as good (and probably better) than a dermatologist—and certainly better than a GP.
Anyway I’m through the system. Five hours after I arrived at the clinic my cancer is in a bottle, and I’ve cycled home and eaten a delicious lunch. Thank you to all involved.
Richard Smith was the editor of The BMJ until 2004.
Competing interest: None declared.