There are several criteria that are useful in establishing how skilled your doctor is managing your skin cancer.
Some criteria that are helpful are:
How many has my doctor managed? Research has shown that the most accurate doctors at diagnosing skin cancer are those who have seen the most. Constant feedback from the pathologist on lesions removed or biopsied acts as a constant ongoing education for the doctor. Any doctor that has removed thousands of skin cancers is going to be accurate at recognising them. A doctor who has seen less than 500 skin cancers will be still experiencing a steep learning curve.
How qualified is my doctor? Has my doctor obtained a post graduate qualification in skin cancer management. Any ACSCM Fellow will be an expert at this area of medicine. Their expertise will extend from diagnosis through surgical skills and reconstruction to follow up of cancers of the skin. An ACSCM Diplomat will be able to manage most skin cancers that he / she comes across in medical practice. There are doctors in Australia who claim a fellowship in skin cancer without ever even sitting an exam! They just handed fellowships to each other like a pat on the back. ACSCM Fellows have all passed a rigorous multicomponent examination process. Our Fellows and Diplomats are listed on this web site so you can verify your doctor's claims to have a real qualification that required rigorous education, training and examination processes.
Does my doctor regularly manage tumours in difficult locations? ACSCM trains doctors in management of skin cancers in all locations, including the lips, nose, eyelids and ears. A doctor not experienced in tumours in these areas will have less overall experience. Doctors that routinely refer such harder cases to others have not obtained the training, experience and skills to manage the diversity of skin cancers.
Satisfaction of patients? Doctors should be responsive to the feedback from patients. Good skin cancer practitioners will have taken steps to evaluate their performance through patient feedback. A lack of complaints is not enough evidence of success. Patients less than happy about their service may still not complain. Patients need opportunities to complete surveys regading their skin cancer treatment without fear or favour.
Recurrence rates Skin cancer is cancer. Like any other cancer, cure rates are a key indicator of performance. If a doctor has a recurrence rate of 8% or higher, that indicates an unaccepatble performance. The best skin cancer practitioners have recurrence rates well under 5% of tumours they manage.
Margins of clearance This is somewhat related to recurrence rates. Some doctors take out skin cancer with very narrow margins of normal skin around the cancer. Narrow margins lead to a higher recurrence rate. If your doctor says that your excised skin cancer is full treated, but the pathologist says there is less than 1 mm of normal skin between the the cancer and the excised surface, then consider another opinion. Accepting narrow margins around cancers means facing unacceptable recurrence rates. Margins are even more important around melanoma, where 10 mm of normal skin is a minimum clearance requirement. Skin can shrink in formalin before the laboratory process the specimen. At the very least the pathologist should report a 6 mm margin of normal processed skin around a fully excised melanoma. If the melanoma is "in situ' it means it is only in the outer skin layer, and only half these indicative distances is required.
Complication rates Ask you doctor about how common he / she experiences complications such as infection, bleeding, wound breakdown and ugly scars following skin cancer surgery. A high complication rate suggests poorer surgical skills. Beware of the doctor who claims to never have complications. Every doctor has complications and good doctors are able to recognise and quantify their complications.
Margin control surgery Selected skin cancers are best managed through this methodical approach. The skin defect is not closed until laboratory confirmation that the the tumour is fully removed. If pathology indicates incomplete excision, further surgery is undertaken and the sample examined under the microscope. The process will continue until the tumour is completely out. Only then is the skin defect reconstructed by the doctor. A quality skin cancer doctor will recognise when this methodical approach is ideal and will either carry out the margin control surgery themselves or refer to someone who does such surgery.
Aspects that are largely unhelpful in determining quality of skin cancer practice:
Flap rates The doctors managing cancers on the nose, lips and ears every day will have higher skin flap rates than those doctors that do not. Doctors that refer harder cases to others will have a very low flap rate. Doctors who only manage skin cancer upon referral will inevitably have highest flap rates. However a higher flap rate does not necessarily mean the skin cancer doctor is better. Because other doctors have been known to effect flaps to close easy defects that could have been closed effectively without the need for a flap. An overall flap rate to close defects is therefore unhelpful. Rather, if you really want a useful figure about your doctor's usage of flaps, ask him / her what percentage of his / her flaps are undertaken on difficult body sites such as the eyelid, nose, lips, ear and fingers. The item number for these flaps (45206 in Australia) is different to the number used in easier locations. If a doctor is doing a lot of flaps but very few are 45206, then that suggests possible inappropriate flap usage. Quite commonly, 45206 comprises a third or more of all flap item numbers claimed by a competent skin cancer practitioner.
Malignant to benign excisions If a doctor only takes off malignant lesions then they are missing some skin cancers by not being "safe" enough. If a doctor is only taking off 1 skin cancer for every 10 lesions excised, then this indicates excessive skin surgery. Good skin cancer practitioners typically take off 1 or 2 skin cancers for every 1 or 2 benign lesions excised. As such, a malignant lesions will typically comprise 33% to 66% of skin lesions managed in the hands of competent skin cancer practitioners.
The doctor managing your skin cancer should be pleased to discuss these aspects with you to help you evaulate their training, experience and expertise.
Other questions about skin cancer management?