Tertiary and joint services
Immunocompromised patients
The Alliance does not host a centre for renal, liver, cardiac or other organ transplants. However the Royal Surrey hosts a visiting Professor in Nephrology from St Helier Hospital with whom patients with skin cancer and renal transplants are closely managed. Liver and cardiac transplant patients with skin cancer or at risk of skin cancer are generally managed in clinics at Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust.
Patients may be immunocompromised due to haematologic disorders or therapies for chronic inflammatory conditions such as rheumatoid arthritis or inflammatory bowel disease. These patients are managed within the Alliance in partnership with their site-specific clinician.
Ashford and St Peter's Hospital has an established skin clinic for immunocompromised patients.
If a patient is immunocompromised, this must be highlighted in letters and clinical notes and to the MDT, along with the reason for immunocompromise, to allow appropriate management.
Mohs surgery
Regional providers include Bav Shergill at Queen Victoria Hospital, Emma Craythorne at GSST, Alan Ah-Weng at Croydon University Hospitals, and Ven Samarasinghe at St Georges.
Mohs surgery can be offered after SSMDT discussion or registration where there is patient preference, and where there is a recurrent Basal Cell Carcinoma (BCC) as per 2021 BAD guidelines. It may rarely be offered for other skin tumours after SSMDT discussion.
Surgeons within the Alliance may offer and carry out standard excision with curative intent and delayed reconstruction where clinically indicated and patients should be offered as an alternative to Mohs surgery where appropriate.
Lymphoma
Primary cutaneous lymphoma
A pathological diagnosis of cutaneous lymphoma should be verified by the specialist pathologist in this field, who is Dr Izhar Bagwan at the Royal Surrey.
Cases of cutaneous lymphoma are referred to the local haematology team, who will be expected to involve the tertiary specialists at Guys and St Thomas' Hospital.
The Alliance recognises the BAD guidelines for the management of primary cutaneous lymphoma (2018) and an update on cutaneous T cell lymphoma (2021).
Under specialist guidance from Guys and St Thomas' Hospital, radiotherapy for cutaneous lymphoma is delivered at the Royal Surrey by Dr Joanna Lynch. CTCL is a very radiosensitive malignancy and several fractions (2–3) of low energy (80–120 kV) superficial radiotherapy are appropriate for many patients. Radiotherapy protocols for cutaneous lymphoma are curated internally by the radiotherapy department at St Luke's Cancer Centre.
Systemic lymphoma involving skin
B symptoms or other symptoms of concern may raise the index of suspicion of a previously undiagnosed systemic lymphoma that has spread to skin as a secondary site of disease. These are almost always B cell lymphomas.
This condition has a significantly worse prognosis that primary cutaneous lymphoma.
Patients should simultaneously be offered a PETCT scan and urgent referral to the local lymphoma lead clinician.
Sarcoma involving skin
Cutaneous sarcomas are generally referred to the Sarcoma unit at the Royal Marsden Hospital with the following exceptions:
pleomorphic dermal sarcoma that is not recurrent, not metastatic and in an anatomic site that does not present special challenges;
fully resectable dermatofibroma protuberans;
localised or limited-field classic Kaposi sarcoma;
any cutaneous sarcoma in patients with advanced age-related or other infirmities (typically WHO PS 3-4), in whom treatment is with palliative intent.
HIV-related Kaposi sarcomas are managed through referral to the Central and North West London NHS Foundation Trust Sexual Health and HIV services at Chelsea and Westminster Hospital, which hosts the National Centre for HIV related malignancy. The named link clinician is Dr Nalin Hettiarachchi.
Skin cancer in the head and neck region
The Alliance SSMDT, unusually among skin MDTs nationally, has strong core oromaxillofacial and head and neck surgeon membership.
Management plans for all skin cancers in the head and neck region will normally be agreed at the SSMDT meeting and executed by SSMDT members, with the following exceptions:
Head and neck mucosal melanoma should, where possible, have a prospective management plan agreed at the SSMDM but the definitive surgical plan will be normally performed by an ear, nose and throat surgeon. If radical surgery has already been performed prior to SSMDT involvement, no further treatment should be offered until full case review and formulation of an agreed management plan at the SSMDT.
Skin cancer patients requiring head and neck reconstruction procedures involving microvascular techniques are referred to a Head and Neck MDT (HNMDT) specialist.
Skin cancer patients requiring parotidectomy and neck nodal dissections are managed by one or more surgeons from the SSMDT or HNMDT, with the appropriate skill mix assembled on a case by case basis.
Periocular skin cancer may be referred to Moorfield's Hospital.
Uncomplicated keratinocyte cancers in the head and neck region may be managed by the local or specialist HNMDT but according to the Alliance SSMDT treatment guidelines. Note that all melanomas and rare or complex skin cancers should have SSMDT input.
Anorectal and intestinal melanoma and non-melanoma skin cancer
Patients with perianal squamous cell carcinoma normally present to the colorectal MDT but should be discussed at the SSMDT. Whereas surgical excision and chemoradiation are longstanding and effective treatments, the introduction of cemiplimab in particular should encourage a joint approach.
Patients with anorectal melanoma should be discussed at the colorectal and SSMDTs, ideally with one treating clinician from either group attending the other meeting. Whilst historically these patients underwent radical surgery, it is increasingly believed that the risk of systemic metastasis dominates their clinical outcome, including the perspective that defunctioning surgery may render major quality of life detriments in patients with sometimes limited life expectancy.
Patients with intestinal involvement by melanoma may be diagnosed after an acute episode, in which case surgery has typically already taken place, or incidentally on PETCT, or with large masses that involve intestine by direct extension. In the latter two cases, careful consideration needs to be given to surgery in combination with systemic therapy, often as an iterative process.
Professor Timothy Rockall at RSH is the designated colorectal surgeon lead for melanoma, and can also advise on escalation to supraspecialist services in case of a need for complex bowel surgery.
Vaginovulval melanoma and non-melanoma skin cancer
Melanoma of the gynaecological tract usually first presents to the gynaeoncology MDT. Once the diagnosis is made, cases should be referred to the SSMDT for histologic review and joint treatment planning.
Joint treatment may for example entail wide local excision of the primary site by the gynaecological oncologist with sentinel lymph node biopsy by the specialist skin surgeon.
In advanced melanoma, treatments may include combination immune checkpoint blockade, and intracavitary brachytherapy for control of bleeding or pain, emphasising the need for close collaboration between the site-specific oncology teams.
Vulvar squamous cell carcinoma is normally managed within the gynaecology MDT.
Professor Simon Butler-Manuel is the designated gyaecological surgeon lead for melanoma.
Skin cancer of external male genitalia
Clinical skin cancer or in situ lesions of the external male genitalia should be referred without initial intervention to Mr Raj Nigam, Consultant Urologist, who has joint appointments at RSH and University College London Hospitals NHS Trust. These patients are discussed at the UCH Urological Cancer MDT meeting.
For infirm or palliative patients, radiotherapy may be administered locally under direction of the UCH MDT.
Management of teenagers and young adults
Within the Alliance, RSH is the designated Teenage and Young Adult (TYA) oncology unit for all cancer patients aged between 16 and 24. Additionally, the TYA service at RSH accepts young people up to the age of 30. The TYA service provides age-appropriate care and support for young people and their families. Systemic anticancer therapy and supportive treatments are administered in a dedicated environment.
Patients aged 16-18 should be referred for diagnosis and treatment at the principal treatment centre, with susbequent shared care arrangements at the local TYA designated hospital (RSH).
Patients aged 19-24 should be offered the choice of having their cancer treatment either at the TYA designated hospital or the principal treatment centre.
All patients with a suspected or confirmed diagnosis of a sarcoma should be referred to RMH (soft tissue) or Stanmore/ UCLH (bone).
The lead nurse for the TYA service is Claire Palles-Clark; the Oncology and TYA teams have worked closely on a number of cases with significant pooled experience and expertise.
A TYA patient information leaflet is available.
Palliative care
All patients with skin cancer will have access as required to appropriate specialist palliative care and support.
Open and frank discussions with patients should take place with patients at all stages of their journey so that patients are not confused about their prognosis or have unrealistic expectations of any of the forms of treatment offered to them.
Relatives and carers will be supported and given appropriate information. In accordance with the recommendations set out in other Improving Outcomes Guidance, relatives and carers should not be given information different to that given to the patient.
The management of symptoms, psychological, social and spiritual issues, the communication of the diagnosis, and any associated problems, should be delivered by appropriate professionals.
The General Practitioner should be informed within 24 hours of the diagnosis and treatment plan when the patient is entering a palliative pathway.
A Primary Health Care Team will provide palliative care at home when appropriate.
Referral to enhanced supportive care or specialist palliative care services should be considered in particular for patients with:
Complex symptom management issues
Difficulties in adjusting to the diagnosis or disease progression
Psychological and family issues – such as communication problems within the family
Spiritual issues – such as the challenging of belief system/faith/cultural values as a result of the cancer.
Consideration of specialist palliative care or support should be given throughout the patient pathway, particularly when no active treatment is considered, after active treatment, at relapse and in the terminal stages. This should be addressed where appropriate at the MDT and a named clinician, normally a CNS made responsibile for instituting a palliative care referral.
Each constituent Trust has acute oncology and palliative care services. In addition the following care providers provide palliative and end-of-life support to patients with skin cancer in the region.
Phyllis Tuckwell Hospice Farnham
St Catherine's Hospice Crawley
Woking and Same Beare Hospice Midhurst
Princess Alice Hospice Esher
Thames Hospice Maidenhead
St Michael's Hospice Basingstoke
Charities and support groups
MelaNoMore, launched in 2019, provides local support and connections between patients.
StoryFMR is raising money for melanoma research activities in the Alliance.