Scripties UMCG - Rijksuniversiteit Groningen
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Evaluatie poortwachtersrol van de huisarts in de huidkankerzorg : een retrospectieve dwarsdoorsnede studie

(2016) Andriessen, D.J.R.S.

Introduction: The incidence of skin malignancies is increasing annually, amplifying the importance of primary care physicians role in diagnosing and treating dermatologic malignancies. It is estimated that 40% of skin lesions excised in primary care offices are not submitted for histopathological examination. Prior studies suggest that clinical diagnosis of primary care physicians is inaccurate, causing potential skin (pre-)malignancies to remain unrecognized. Furthermore, skin malignancies are more often radically excised by dermatologists than by primary care physicians. The role of the primary care physician is to recognize pre-malignancies as early as possible and then initiate an appropriate follow-up; either with a specialized care referral or treatment in the primary care office. In our opinion prior research lacks full information to draw conclusions on the clinical diagnosis of the primary care physician in skin malignancy care.
Study objective: To gain insight in the recognition of skin malignancies by primary care physicians and the effect of the clinical suspicion on the radicality of the cutting surfaces of the excised skin lesion. Methods: A retrospective cross-sectional study was performed; all skin excisions completed and sent in by primary care physicians in the catchment area of Isala during a 4 year timeframe were analysed. First, the histopathological diagnoses were grouped into either the benign or malignant category. The paired differential diagnosis and the general practitioner malignancy scale (1=definitely benign, 5=definitely malignant) were compared to the histopathological diagnoses. Second, the effect of a clinical suspicion of a (pre)malignancy or lack thereof on the percentage of radically excised skin malignancies was studied. Results: This study shows general practitioners predict a correct histopathological diagnosis based on the clinical suspicion in only 38.1%. However, when combining the differential diagnosis with the general practitioner malignancy scale, the general practitioners predict the correct histopathological nature of 78.9% of the (pre-)malignant lesions. Furthermore, this study showed that 1 in 22.7 skin excisions with no clinical suspicion for malignancy was diagnosed as a (pre)malignancy. One in every 200 skin lesions without any suspicion turned out to be a melanoma. The cutting surfaces of excised lesions were non-radical in 29.9%.The highest percentage, 43.2%, of non-radicality was found in the head-neck area.
Conclusion: Primary care physicians are quite capable of recognizing skin malignancies; however, 1 in 200 skin lesions with no clinical suspicion of malignancy turned out to be a melanoma. Therefore, to improve the accuracy of recognition, a guideline on “suspicious skin lesions” by the Dutch primary care physician society (Nederlands huisartsen genootschap, NHG) is necessary. Considering the high percentage of non-radical excisions of skin malignancies in the head-neck area, we advise primary care physicians to first take a biopsy of lesions in the head-neck area when there is a clinical suspicion of malignancy. When there is a histopathological diagnosed malignancy, we advise them to refer their patients to specialized care.

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