This consultation was received directly from SIGN asking RCPE to review those sections of the draft guideline which relate to the College's area of expertise. SIGN is primarily interested in the College's view on the comprehensiveness and accuracy of interpretation of the evidence base supporting the recommendations in the guideline although any comments on the style or presentation were also invited.
The College was asked to include key references to support our comments on this evidence-based guideline wherever possible, and list our comments by the guideline section number.
Comments on Scottish Intercollegiate Guideline Network (SIGN)
SIGN Guideline: Management of Primary Cutaneous Squamous Cell Carcinoma
The Royal College of Physicians of Edinburgh (the College) is pleased to respond to the call for comments on the draft SIGN guideline on the Management of Primary Cutaneous Squamous Cell Carcinoma (SCC).
General comments
The College feels that the guideline is well structured and will assist in addressing concerns such as treatment variability amongst practitioners currently managing SCCs and the poor rate of reporting to the Scottish National Cancer Registry.
The document lists key questions used to draft the guideline, such as what are the most effective interventions for management of patients with primary invasive cutaneous squamous cell carcinomas, and the College feels that the guideline group has applied the available evidence base well, recognising there are gaps requiring further research which have been highlighted.
The importance of stratifying risk has been highlighted and the use of the multidisciplinary team to ensure best practice has been recommended.
Audience
The document details that the target audience includes dermatologists, histopathologists, occuloplastic, oral/maxillofacial and plastic surgeons, skin cancer clinical nurse specialists, oncologists, general practitioners, patients and their families. The College feels this document has covered all aspects of squamous cell carcinoma to include the interests of these different groups. The majority of it is most useful for those treating squamous cell carcinoma in secondary care. However, the document is quite lengthy and it would be useful to have a summary aimed at those in primary care and possibly a separate summary aimed at those in secondary care. This would hopefully make the guideline more ‘user friendly’ and increase the chances that the guideline is acknowledged and adhered to.
References
The College feels that the evidence base is comprehensive where this has been possible. High quality evidence has been given a grading labelled with an R, less high quality evidence received a simple tick within a box. The ‘R rating’ does not seem to be documented within a key at any point in the paper. In comparison, on the second page it is noted that a tick within a box indicates ‘recommended best practice based on the clinical experience of the guideline development group’. It would therefore be useful to include a definition for the ‘R rating’.
Comments on specific sections of the draft guideline
Section 4
Section 4 details high risk features of primary SCC which would merit referral of the lesion to a skin cancer MDT. It is likely that this will significantly increase the number of tumours requiring discussion at a regional skin cancer MDT. While it is not necessarily the remit of this guideline, it would be useful to see an indication as to the estimated number of lesions which fall into this high risk group.
Section 5
There is limited published evidence on a number of these treatment modalities and it might be appropriate to include the option of discussion with patient as to best option for them. It would also be helpful if there was further clarity in the guideline on what constitutes “immunosuppression” in this context.
Section 6
There are currently regional variations in the follow up protocol for primary cutaneous squamous cell carcinoma. The College is aware of the West of Scotland Cancer Network (WOSCAN) consensus follow up schedule for high risk primary cutaneous squamous cell carcinoma of 2-3 months for 1 year then 4 monthly for 1 year; very high risk primary cutaneous squamous cell carcinoma of 2 monthly for 1 year then 4 monthly for 1 year then yearly for 3 years. This is different to that quoted in the draft SIGN guideline (follow up appointments every 3-6 months for 24 months, 1 further appointment at 3 years). The final recommended schedule of follow up will impact on resources and it would be helpful to understand the differences in common practice.
Section 9.2
An important aspect of this paper is section 9.2 which details recommendations for future research. Due to the paucity of high quality evidence in certain areas it has been necessary to recommend management as ‘best practice based on the clinical experience of the guideline development group’ regularly throughout the guideline.
Fellows of the College advise that one aspect which is difficult to ensure is the consistency of pathology reporting. The College therefore welcomes the inclusion in the annex of an SCC minimum dataset adapted from the Royal College of Pathology. It would perhaps be beneficial for the Royal College of Pathology to be involved in review of these guidelines with the intention that they could recommend methods to improve the uptake in use of such a minimum dataset.