• Dermatologists. There should be at least two dermatologists, one of whom should have a major interest in skin cancer and/or skin cancer surgery; another should ideally have a major interest in cutaneous lymphoma. There should be a designated lead and ideally a deputy lead, and any dermatologist involved in skin cancer care should attend the MDT meeting.
• Surgeons. At least two surgeons should have a designated interest in skin cancer surgery and perform at least 15 block dissections each (groin or axilla) per year. Radical or conservative neck dissections (for cancer of the head and neck) should only be done by specialists regularly undertaking this procedure or who are members of the head and neck cancer MDT. A combination could include plastic surgeons, surgical oncologists, oral and maxillofacial surgeons, oculoplastic surgeons and ear, nose and throat (ENT) surgeons. It may be appropriate locally to include as extended team members oculoplastic surgeons and reconstructive hand surgeons. Oculoplastic surgeons have a specific and important role in the management of skin cancers arising around the eye.
• Skin cancer CNSs (as defined by the Department of Health (2004) Manual of Cancer Services. Available from: www.dh.gov.uk). Patient advocacy and provision of information and support for patients and carers are crucial aspects of this role. The CNS will play a key role in communication between the patients and the different specialties involved in management and must have a high level of communication skills. She or he should be able to provide practical support such as advice postoperatively. The CNS will also have an important role in the identification of patients' psychosocial needs and will advise on appropriate referral. The CNS may, if suitably trained, carry out a range of related service activities such as minor surgery, skin cancer surveillance and follow-up clinics in parallel with an appropriately trained doctor.
• Histopathologists. Ideally there should be at least two specialist dermatopathologists or histopathologists with a special interest in dermatopathology. This is to provide flexibility and adequate cover during leave periods. There should be a designated lead in the area and ideally a deputy lead. The lead and deputy lead engaged in reviewing and reporting SSMDT skin cancer cases should each attend over 50% of SSMDTs. Other histopathologists reviewing and reporting SSMDT work should be able to demonstrate some MDT activity. All specialist histopathologists reviewing and reporting common and rare skin cancers should be able to demonstrate experience, competency and skills sufficient to fulfil the task, or undertake appropriate training to acquire the skills. The level of competence and skills for this activity is broadly that of the RCPath Diploma in Dermatopathology and American Board Certification in Dermatopathology. These qualifications are not, however, regarded as mandatory. All specialist histopathologists engaged in this work should participate in some continuing professional development (CPD) relevant to common and rare skin cancers and participate in an appropriate EQA scheme. Ideally this should be a national specialist EQA scheme in dermatopathology, when available. Those reporting primary cutaneous lymphoma must participate in an EQA scheme including this group of diseases. It is also desirable that the CPD is facilitated by membership of appropriate national societies (such as the British Society for Dermatopathology and/or the UK Cutaneous Lymphoma Group). Each cancer or pathology network could hold a panel of histopathologists suitable for SSMDT participation based on these criteria.

  Histopathologists restricting their activity in the SSMDT centre to work at the LSMDT level should be able to demonstrate the same activity as defined previously. It is acknowledged that because of workforce shortages in histopathology there could be an implementation delay of these goals in some centres.

• Radiologists. Cross-sectional imaging is important for staging new cases and managing advanced cases. Sessional time must be identified to allow the radiologists to prepare for and attend the MDT meeting.
• Clinical oncologists. A designated clinical oncologist should be identified as a member of the SSMDT and should be present in both the clinic and MDT review meeting.
• Medical oncologist. A designated medical oncologist should be identified as a member of the SSMDT and should be present in both the clinic and MDT review meeting.
• Palliative care specialists. Since the management of complex invasive skin cancers (particularly metastatic MM) is often palliative, a palliative care specialist (either a doctor or a nurse) should be included in the core team. Patients with specialist palliative care needs should also be referred to the appropriate community palliative care services.
• Team coordinator/secretary. A team coordinator/secretary should provide clerical support, record meetings and ensure that all documentation required to inform MDT discussion is available at each meeting.
• For each of the specialties described above there should be a nominated lead and deputy.

Members of the Extended SSMDT

The core members and those in the list below form the extended multidisciplinary team that meets at least once a year to decide and discuss local issues of service delivery and quality. The trust cancer services managers should attend such meetings.

The extended SSMDT may include:

• Trained counsellors with experience in cancer
• Psychologists
• Liaison psychiatrists
• Pharmacists
• Cosmetic camouflage service advisers
• Clinical geneticist/genetic counsellors
• Lymphoedema therapists
• Occupational therapists
• Prosthetics and orthotics staff
• Physiotherapists
• Radiographers
• Speech and language therapists

Commissioning arrangements should be made by the cancer network for the funding of histopathology reviews from the LSMDT to the SSMDT, and by the cancer network for funding supranetwork pathology referrals from the SSMDT for tertiary opinions in difficult diagnostic cases.

Organisation of LSMDT and SSMDT Meetings

The core LSMDT and SSMDT should meet at least every 2 weeks. The MDT should assume responsibility for all cases of skin cancer referred to them. All team members should attend the majority of meetings and should participate in collaborative decision-making, although different criteria apply to GPwSIs. At least once a year the LSMDT and SSMDT extended teams should meet with their core teams to discuss team and organisational issues with a designated trust manager.

Decisions about management and standards for therapy should follow documented clinical protocols that have been agreed throughout the network. These protocols should be demonstrably evidence-based and should be produced jointly by members of all the teams in the network that deal with skin cancer. Patients who fit the criteria for inclusion should be asked if they would like to participate in NRCN- and WCTN-recommended clinical trials.

Medical photography has an important role in the recording of clinical images for skin lesions and should be used where appropriate to aid decision-making at MDT meetings.

One member of the LSMDT/SSMDT (usually the lead clinician) should take managerial responsibility for the service as a whole. Audit of process and outcomes, and actions arising from audit results, should be discussed in team meetings (see table above titled "Example of activities in a rolling programme of audit"). Data collection systems should be compatible across pathology departments and all skin cancer teams to facilitate network-wide audit.

Meetings should be arranged by the team secretary/coordinator, who should ensure that information necessary for effective team functioning is available at each meeting. This will include a list of patients to discuss and copies of their case notes, along with diagnostic staging and pathology information.

Preparation and attendance at meetings should be recognised as a clinical commitment, and time should be allocated accordingly and reflected in consultant job plans. Team members should be adequately prepared for each meeting, so that cases can be discussed without delay. The team should elect a lead clinician who takes managerial responsibility and represents the team on the skin cancer network site-specific group.

Videoconferencing and teleconferencing should be considered to facilitate the holding of MDT meetings, especially in geographically dispersed areas and where time is a severe constraint.

All new cases should be discussed as well as those that have subsequent events following initial assessment and treatment. Straightforward cases treated to agreed national and local protocols may need very little discussion, but should be included.

Audit, clinical trials and other issues of relevance to the network should also be discussed at MDT meetings.

Clinicians Working in the Community

As described in the Background chapter (see the original guideline document), precancerous lesions of the skin and skin cancers are extremely common. Therefore, all GPs will be expected to recognise and make management decisions on patients with these conditions on a regular basis. This guidance recommends that while precancerous lesions can be safely managed by any GP who has undergone appropriate training (as outlined in the National Guideline Clearinghouse [NGC] summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children), the planned treatment of low-risk BCCs should be restricted to approved doctors working in the community, usually a GPwSI (as described in this section in the original guideline document), or the LSMDT/SSMDT. All other skin cancers should be referred to the LSMDT in the first instance.

In some areas, there may be suitably trained doctors who work in specialist hospital departments and who wish to see and treat patients with precancerous skin lesions and low-risk BCCs in the community. The need for community skin cancer clinics will vary according to the expertise available and ease of access to local hospital departments – they may well be more appropriate in rural areas than in urban areas. All doctors and specialist nurses working in the community who knowingly treat skin cancer patients should be approved by, and be accountable to, the local LSMDT/SSMDT skin cancer lead clinician. They should work closely together to agreed local clinical protocols for referral, treatment and follow-up. These should be coherent with network-wide clinical protocols and signed off by the network site-specific lead for skin cancer.

Depending on local circumstance, community skin cancer clinics could be based in GPs' surgeries, community hospitals or diagnostic and treatment centres where these exist. Patients could be referred to these clinics by local GPs or members of the LSMDT/SSMDT. For instance, when a diagnosis of low-risk BCC is made in a dermatology clinic, the patient may prefer the surgery to be carried out in the community if the specialist agrees this to be appropriate. Patients could be seen by these teams for treatment and follow-up when appropriate, according to agreed protocols and patient choice (see Box below and Figure 14 in the original guideline document for details of the patient pathway for different types of skin lesions).

Any doctor or specialist nurse who wishes to treat patients with skin cancer should have specialist training in skin cancer work, be a member of the LSMDT and undergo ongoing education (see section on "Structure and Clinical Governance"). In the absence of a national body to determine the surgical training within the remit of skin cancer, this should be determined by the network site-specific group for skin cancer and be consistent with the NGC summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children. All doctors participating in the MDT should have a letter of appointment from the MDT lead clinician. Ideally all doctors treating patients with skin cancer should have attended a recognized skin surgical course. They should also work at least one session per week as a clinical assistant, hospital practitioner, associate specialist or staff-grade doctor in the local hospital department. This should be in a parallel clinic with an appropriate hospital specialist, normally a dermatologist, who is a member of the LSMDT/SSMDT. This applies to GPwSIs as well, as specified in the joint recommendations by the Department of Health (DH), Royal College of General Practitioners (RCGP) and the British Association of Dermatologists (BAD). This is considered essential to maintain skills and promote dialogue with the specialist.

A basic knowledge of skin cancer histopathology reporting and terminology is expected. Eligible doctors should either be GPwSIs employed by the primary care trust (PCT) /local health board (LHB) or non-career-grade doctors employed by the hospital trust. PCTs and LHBs should only accredit GPwSIs for skin cancer work if they comply completely with the DH, RCGP and BAD guidelines on GPwSI working. The recommendations include the need for the GPwSI to work at least one session per week in the special interest area. The majority of the practitioner's time should be spent as a GP, and this is usually considered to be at least three sessions per week.

Skin cancer CNSs should work alongside the doctors and carry out some forms of treatment such as cryotherapy, skin surgery and photodynamic therapy. They would also be involved in counselling, health promotion and follow-up of selected groups of patients where appropriately trained and would also ensure that the necessary liaison occurs between the hospital and community-based care. Any doctor, nurse or other practitioner who carries out surgical procedures on skin cancer patients should be appropriately trained and have his or her work audited and appraised.

The Role of the Doctor Working in the Community

The doctor working in the community should:

• Manage and follow up, when indicated, patients with low-risk BCCs and precancerous lesions in the community (see the Box below titled "Clinical guidelines for primary care on the management of skin cancer and precancerous lesions" and Figure 14 in the original guideline document) by working to agreed protocols as defined by the lead clinician of the LSMDT/SSMDT.
• Provide a rapid referral service for patients who require specialist management through the LSMDT or SSMDT.
• Be responsible for the provision of information, advice and support for patients managed in primary care and their carers.
• Maintain a register of all patients treated, whose care should be part of a regular audit presented to the LSMDT/SSMDT.
• Liaise and communicate with all members of the skin cancer site-specific network group.
• Ensure that referring GPs are given prompt and full information about their patients' diagnosis or treatment in line with national standards on communication to GPs of cancer diagnoses.
• Collect data for network-wide audit

Management of Patients Presenting in Primary Care

The NGC summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children recommendations for skin cancer should be followed. These primarily relate to referral to a specialist in secondary care from a non-specialist GP.

Clinical guidelines have been published by the BAD and National Institute for Health and Clinical Excellence (NICE) for management of non-melanoma skin cancer (NMSC) and by the BAD, British Association of Plastic Surgeons, Melanoma Study Group and NICE for the management of MM. The recommendations for management of specific tumour types in primary care are summarised in Figure 14 in the "Initial Investigation, Diagnosis, Staging and Management" chapter of the original guideline document and are consistent with these clinical guidelines. These clinical guidelines have also been included within the Evidence Review.

Structure and Clinical Governance

All clinicians who see and plan to treat patients with skin cancer in the community should be approved by, and be accountable to, the LSMDT lead clinician, and work to agreed protocols.

The work carried out should be audited on a regular basis and staff and resources made available for this. The LSMDT/SSMDT should be responsible for how these audits are organised and carried out. All doctors and nurses should have regular CPD and would be expected to attend the LSMDT/SSMDT meetings whenever one of their patients is being discussed, and at least four times a year. In addition, meetings to discuss audit results, guidelines and cancer measures should be arranged twice a year and all team members should attend these at least once year.

Initial Investigation, Diagnosis, Staging, and Management

Box. Clinical guidelines for primary care on the management of skin cancer and precancerous lesions (see definitions of types of lesion in "Glossary of terms," Appendix 6 in the original guideline document)

Investigation and Diagnosis

GPs should receive training as recommended in the NGC summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children on the diagnosis of precancerous and cancerous lesions, and should receive feedback through audit on their diagnostic accuracy.

GPs should refer certain groups of skin lesions as described in the Box above titled "Clinical guidelines for primary care on the management of skin cancer and precancerous lesions" and Figure 14 in the original guideline document directly to an LSMDT without biopsy. This practice should be subject to audit.

All excised skin specimens should be sent for histopathological examination as recommended in the NGC summary of the NICE Referral Guidelines for Suspected Cancer.

Dermatoscopy should be available in all MDTs, but its use requires training.

There should be equity of access so that all tissue samples are reviewed in high-quality histopathology services. Accurate diagnosis in dermatopathology depends on clinicopathological correlation, involving input from both clinician and pathologist. Although this can be achieved in difficult cases by interspecialist discussion or seeing the patient records, in some instances (such as cutaneous lymphoma) it may be essential for the patient to be seen jointly. Accordingly, for good clinical governance, it is recommended that the histopathology reporting of any specimens likely to be considered by a skin cancer MDT should be undertaken in a laboratory having easy access to relevant clinicians, patient records and the attending patient.

Histopathology services for skin cancer should be part of a managed pathology network or equivalent model.

Histopathology reporting should be provided by histopathologists who participate in EQA. This may be a general histopathology EQA scheme that includes skin or a more specialist skin EQA scheme. When appropriate, the EQA scheme should cover lymphoma. Given the overlap with head and neck cancer services, it should be noted that the head and neck histopathology EQA scheme includes skin cases.

All histopathology reports relating to skin cancer should conform to the Royal College of Pathologists minimum datasets on cancer in order to provide adequate and appropriate information on prognosis, planning individual patient treatment, supporting epidemiology and research, and to evaluate clinical services and support clinical governance.

Sentinel node biopsy (SNB) samples for skin cancer should be examined and reported by specialists with a registered qualification in histopathology. It is desirable that SNB samples resulting from skin cancer are handled and reported by the same team of pathologists involved in the reporting of skin cancer. The technical processing of SNB samples must conform to recognised national or international protocols (such as that used by the European Organisation for Research and Treatment of Cancer (EORTC).

All MMs and severely atypical naevi should be double-reported if resources allow the report to be generated within 2 weeks. The acknowledged current shortfall of an National Health Service (NHS) histopathology workforce in some centres could delay this quality recommendation. Although it is ideal that all melanocytic lesions are double-reported to avoid missing MM, it is likely to be many years before the NHS histopathology workforce could achieve this.

Given an adequate histopathology workforce in the medium to long term, it is desirable that eventually all skin cancers are double reported to achieve consistency and accuracy in diagnosis. It is also recognised that alternative models to double-reporting of MM exist, such as consensus meetings outwith the MDT. These are equally acceptable so long as all potential MDT cases are discussed and the meetings formally minuted with regard to attendance and diagnosis.

All cases referred to the SSMDT should have a specialist histopathology review.

An appropriately resourced national system for histopathology tertiary review should be established. Currently, several thousand complex and/or rare skin cancer cases per year require tertiary opinions from a small number of informally recognised national expert specialist dermatopathologists. Even with the formation of larger pathology networks, the complexity of these cases indicates that this tertiary referral practice will continue to be necessary to obtain the correct diagnosis and thereby maximise the quality of patient treatment and care. All SSMDT cases falling into this category should have full access to this tertiary referral facility when supported by the SSMDT. Commissioners should be aware of the funding implications. These services, which may cross many network boundaries, should be commissioned through the specialised services commissioners.

MDTs should complete the national cancer datasets for common skin cancers and for lymphoma.

Management of Precancerous Lesions

Where there is any doubt about the diagnosis, the patient should be referred for a specialist opinion as described in see the Box above titled " Clinical guidelines for primary care on the management of skin cancer and precancerous lesions" and Figure 14 in the original guideline document. All excised skin specimens should be sent for histopathological examinations as recommended in the NGC summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children.

Patients with two or more atypical naevi, and giant congenital naevi where there is a suspicion of malignant transformation, and who need assessment and education should be referred to a member of the LSMDT or SSMDT (see "Organisation of Skin Cancer Services" and the tables above titled "Patients to be referred for LSMDT review" and "Patients for review by SSMDTs").

Medical photography has a special role to play in surveillance for patients with atypical naevi. Therefore all departments treating skin cancer should have access to high-quality medical photography and storage of digital images.

Any doctor or nurse who knowingly treats patients with precancerous lesions should have received locally approved training in available treatments.

Patients with anogenital Bowen's disease (including penile and vulval)  should be referred to relevant specialist centres, and this may include referral to a urologist, gynaecologist or coloproctologist, depending upon local expertise.

Any patient with a lesion suspected of being lentigo maligna needs to be referred to and managed by a hospital-based member of an LSMDT/SSMDT.

All treatments identified in this chapter for the treatment of precancerous lesions should be available for use by clinicians in all of the teams, subject to locally agreed standards of competence.

Management of Skin Cancers

All excised skin specimens should be sent for histopathological examinations as recommended in the NGC summary of the NICE Referral Guidelines for Suspected Cancer in Adults and Children.

Only doctors and nurses who have received locally approved training and who are active members of a skin cancer MDT should carry out surgery for skin cancers. Scar placement and management should be considered before surgery.

Mohs surgery should be available in each cancer network and only carried out by those who have received training approved by the lead clinician of the skin cancer site-specific network group.

Patients should be given information and be involved in decision making, as set out in the "Patient-Centred Care" section above.

SNB should only be undertaken in centres where there is clinical experience of the procedure and normally only within the context of ethics-committee-approved clinical trials. However, in order to maintain their already established expertise, centres may continue to offer SNB between trials.

Chemotherapy should be available for the management of skin cancer patients where appropriate.

Adjuvant alfa interferon treatment should only be given as part of a clinical trial.

Treatments using surgery and carbon dioxide laser techniques should be available at regional centres via SSMDTs, but isolated limb perfusion (ILP) and isolated limb infusion (ILI) would only be required at supraregional centres.

Vaccine therapy for advanced MM remains uncertain and its use should only be in the context of a clinical trial.

Before non-surgical treatment, a tissue sample for confirmation of the diagnosis should usually be obtained.

Histopathology services should be adequately staffed and resourced to cope with the potential increase in skin biopsies resulting from the recommendations in this guidance. Commissioners should note, however, that acknowledged current workforce shortages could delay this implementation.

NHS histopathologists in England and Wales must work in laboratories that are seeking or have accreditation with Clinical Pathology Accreditation Ltd.

All cancer networks should have easy access to appropriate immunophenotypic, molecular biological and cytogenetic facilities. Some of the latter are very specialised pathology services and may not be provided by pathology laboratories within the LSMDT or SSMDT. Cancer networks should identify one or more clinical oncologists and medical oncologists with responsibility for the radiotherapy and systemic treatment of patients with skin cancer.

Radiotherapy departments should have the appropriate equipment including orthovoltage radiotherapy machines for the management of patients with skin cancer.

All treatments identified in this chapter for the treatment of skin cancer should be available for use by clinicians in all of the teams, subject to locally agreed standards of competence.

Follow-up

Cancer networks should develop locally agreed protocols for follow-up of each skin cancer type, taking into account national guidelines, the risks of local recurrence, metastatic spread and new primary lesions.

Follow-up for patients after treatment for skin cancer should be tailored, as much as possible, to the individual, taking into account the patient's needs and wishes. Options and decisions regarding follow-up should be made jointly with the patient.

All patients should be given both oral and written information about the different types of skin cancer and instruction about self-surveillance. All patients should be given written instruction on how to obtain quick and easy access back to see a member of the LSMDT/SSMDT when necessary. GPs should be given advice about local arrangements for patients to re-access skin cancer services.

Follow-up arrangements may include a combination of self-surveillance, GP or other community doctor, and specialist nurse or hospital specialist clinic.

Some patients, such as those who are immunocompromised or who have a genetic predisposition to the development of skin cancers (e.g. Gorlin's syndrome, xeroderma pigmentosum), may need lifelong surveillance (see "Management of Special Groups" section below).

Positron emission tomography (PET) scanning is not routinely recommended for follow-up; however, it may be useful for a small number of patients with suspected recurrent disease when clinical doubt remains after other forms of imaging. PET scanning should therefore be available on a supraregional basis for these patients.

Basal Cell Carcinoma and Squamous Cell Carcinoma

Patients with BCCs or SCCs, with a low risk of recurrence, do not need long-term surveillance and should be discharged from formal follow-up, but should be given information and instruction as recommended above.

Patients who are at high risk of recurrent or metachronous cancer or who find self-examination difficult require formal follow-up. The period of time and frequency will depend on the degree of risk, which should be discussed with the patient. This may be particularly important for patients with high-risk SCCs, because of the more serious implications of locoregional recurrence.

Melanoma

Patients with in situ MM do not require follow-up, but should be given information and instruction as recommended above.

Patients with invasive MM should have a period of formal follow-up, the frequency and duration of which depends on the risk of metastatic spread and which should take into account the patient's psychological and emotional needs. Detailed recommendations for patients are made in the BAD guidelines for MM.

Patients who have had multiple primaries or those with a family history of MM require long-term follow-up, sometimes lifelong.

Management of Special Groups

Generic Recommendations For Patients With Uncommon Risk Factors or Rare Cancers

Specialised services commissioners, together with their cancer network(s), should undertake a needs assessment for these special groups of patients, plan the provision of appropriate specialist care and put in place the necessary commissioning arrangements.

Network-wide protocols should be developed that describe the pathways of care for these special groups of skin cancer patients.

Commissioners should receive results of audits of the care of these special groups. Commissioning for national specialised pathology services for rare skin tumours should be reviewed by the specialised services commissioners.

There should be good liaison between the SSMDT and the haemato-oncology MDT. Specifically, systemic/nodal lymphomas presenting in the skin should have haemato-oncology MDT review. Likewise, primary cutaneous lymphoma presenting to, for example, haematologists should receive SSMDT review.

There should be a close liaison between the SSMDT and the soft tissue sarcoma MDT. It is appropriate for many cutaneous sarcomas to be considered by the SSMDT but some should also be discussed at the sarcoma MDT, especially those that penetrate the superficial fascia or require chemotherapy.

Information provision for patients in these special groups should be tailored to their specific needs and contain information on their condition and relevant patient support groups. Links should be made to national support groups, to assure the quality of information (see "Patient-Centred Care" above).

Treatment strategies for individual patients should be made and developed in the context of MDT meetings at which all relevant clinical specialists, including a CNS who knows the patient, should be present.

All patients with a high risk of developing skin cancer should be counselled effectively by a dermatologist or a CNS about sun protection before they develop any skin lesions, and should have annual checks carried out thereafter.

All patients in high-risk groups with precancerous skin lesions (e.g. multiple warty lesions and/or actinic keratoses [AK]) should be referred early to a dermatologist for assessment, active treatment and follow-up.

Once patients at high risk start to develop skin lesions they should be offered at least 6-monthly follow-up.

Genetic Predisposition

Patients with evidence of genetic predisposition and their families should be offered referral to the clinical genetics services or a specialist dermatology service. The criteria for referral for families with MM are:

• Three or more family members with MM
• Two first-degree relatives with MM
• Two relatives with MM, one of whom had multiple primaries

Patients with familial MM, Gorlin's syndrome or XP should be reviewed by SSMDTs and be managed by dermatologists and surgeons who have expertise in these conditions.

Patients with Gorlin's syndrome should not be treated with radiotherapy.

Transplant Patients

Transplant patients who have precancerous skin lesions or who have developed a skin cancer should be seen in a dedicated 'transplant patient skin clinic', either in the transplant centre or in a hospital closer to the patient's home, according to the choice of the patient.

Close links should be established between the transplant centre, local physician and dermatologist for the management of transplant patients postoperatively.

Dermatologists managing transplant recipients with multiple and/or recurrent skin cancers need to liaise with the transplant team regarding reduction of immunosuppression and the use of systemic retinoids in order to reduce the risk of invasive disease.

Cutaneous Lymphoma

All patients should be seen by and managed by the SSMDT, which should include a dermatopathologist with expertise in cutaneous lymphoma (NICE guidance on Improving Outcomes in Haematological Cancers). Close liaison should be maintained with a haemato-oncopathologist, as appropriate. Cases of possible systemic haematological malignancy involving the skin should be referred to the appropriate haematological malignancy MDT.

LSMDTs should be involved once the diagnosis and staging has been confirmed by the SSMDT.

Patients with lymphomatoid papulosis or stage Ia mycosis fungoides could be managed locally by the LSMDT after diagnosis.

Patients with rare types of cutaneous lymphoma and those with later stages of mycosis fungoides (stage IIb or above) should be seen in and have easy access to supranetwork centres for specialist advice and access to treatment facilities. There should be a small number of such centres nationally and they would not be present in every cancer network.

These supraregional services should be commissioned under regional specialised commissioning so that the expertise can be concentrated where the treatment facilities are available and so that tertiary referral centres can undertake clinical studies based on a meaningful number of patients.

All lymphoma patients should undergo diagnostic biopsies for histology, immunophenotyping and molecular studies, and this should be correlated with clinical presentation for accurate diagnosis and prognosis.

The SSMDT should have access to specialist laboratory testing of tumour tissue and blood for immunophenotyping, molecular analysis and blood viral serology.

Initial staging imaging is required in all patients with the exception of stage 1 mycosis fungoides and lymphomatoid papulosis.

The SSMDT should have access to bone marrow aspirate and trephine biopsies for complete staging of all patients with B- and NK-cell lymphomas and for patients with cutaneous T-cell lymphoma (CTCL) variants and late stages of mycosis fungoides (stage IIb or above).

The World Health Organization (WHO)–EORTC primary cutaneous lymphoma classification should be used to classify primary cutaneous lymphomas.

Chemotherapy should be reserved for patients with advanced disease as it may have a detrimental effect on those with early disease.

Skin Sarcomas

Skin cancer MDTs should liaise with sarcoma MDTs in the management of patients with cutaneous sarcomas. As stated in the section on SSMDTs, it is essential for all cutaneous sarcomas to receive specialist histopathology review.

Sarcomas needing SSMDT review include all those involving the dermis and subcutaneous fat above the superficial fascia. It is appropriate for small/superficial cutaneous sarcomas to be dealt with by the SSMDT.

It is essential that there is close liaison between the SSMDT and sarcoma MDTs. This is particularly important for patients whose sarcomas are large or penetrate the superficial fascia or are of a histological type requiring chemotherapy (e.g. rhabdomyosarcoma, Ewing's sarcoma).

Patients with Kaposi's sarcoma should be referred to experts in the management of this tumour.

Children and Young People

All children and young people diagnosed with skin cancer should be managed within the context of an MDT, which will include a dermatologist expert in skin malignancies and have access to specialist children and young people cancer support services and inpatient facilities at network level (see NGC summary of the NICE service guidance Improving Outcomes in Children and Young People with Cancer).

Children and young people with skin cancer should be given the opportunity of entering into National Cancer Research Institute-(NCRI)-approved clinical trials, as recommended in the NGC summary of the NICE service guidance Improving Outcomes in Children and Young People with Cancer.

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site.

• National Collaborating Centre for Cancer. Guideline Development Methods: Information for National Collaborating Centres and Guideline Developers. London (UK): National Institute for Health and Clinical Excellence (NICE); 2005 Feb. 89 p. Electronic copies: Available from the National Institute for Health and Clinical Excellence (NICE) Web site.
• National Collaborating Centre for Cancer. Improving outcomes for people with skin tumours including melanoma. The evidence review. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Feb. 584 p. Electronic copies: Available from the National Institute for Health and Clinical Excellence (NICE) Web site.
• National Collaborating Centre for Cancer. Improving outcomes for people with skin tumours including melanoma. Analysis of the potential economic impact of the guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Feb. 62 p. Electronic copies: Available from the National Institute for Health and Clinical Excellence (NICE) Web site.

Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site.

Print copies: Available from the National Health Service (NHS), 11 Strand, London, WC2N 5HR. Response Line 0870 1555 455, ref N0958.

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