Background - RSTN
4560458-38862000National audit of Non-Melanoma Skin Cancer excisions by Plastic Surgery in the United Kingdom (NMSC: PlastUK)Protocol version 2.3NMSC: PlastUK working groupGrant Nolan, Anna Allan, Benjamin Smeeton, Justin Wormald, Ailbhe Kiely, Matthew Gardiner, Rowan Pritchard Jones, Abhilash Jain BackgroundNon-melanoma skin cancer includes basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). They are the commonest cancers in the United Kingdom (UK) accounting for 20% of all new malignancies ADDIN EN.CITE <EndNote><Cite><Author>National Cancer Intelligence Network (NCIN)</Author><Year>2013</Year><IDText>Non-melanoma skin cancer in England, Scotland, Northern Ireland, and Ireland</IDText><DisplayText><style face="superscript">1</style></DisplayText><record><titles><title>Non-melanoma skin cancer in England, Scotland, Northern Ireland, and Ireland</title></titles><contributors><authors><author>National Cancer Intelligence Network (NCIN),</author></authors></contributors><added-date format="utc">1571626495</added-date><ref-type name="Generic">13</ref-type><dates><year>2013</year></dates><rec-number>238</rec-number><last-updated-date format="utc">1571626523</last-updated-date></record></Cite></EndNote>1. The UK incidence is 124-148 per 100 000 person years ADDIN EN.CITE <EndNote><Cite><Author>National Cancer Registration and Analysis Service (NCRAS)</Author><Year>2013</Year><IDText>Non-melanoma skin cancer: Incidence and </IDText><DisplayText><style face="superscript">2</style></DisplayText><record><titles><title>Non-melanoma skin cancer: Incidence and 
 mortality rates in England, Scotland, and Northern 
 Ireland</title></titles><contributors><authors><author>National Cancer Registration and Analysis Service (NCRAS),</author></authors></contributors><added-date format="utc">1571626295</added-date><ref-type name="Generic">13</ref-type><dates><year>2013</year></dates><rec-number>237</rec-number><last-updated-date format="utc">1571626353</last-updated-date></record></Cite></EndNote>2. Annually skin cancer (including melanoma) is estimated to cost the NHS over ?180 million in 2020 ADDIN EN.CITE <EndNote><Cite><Author>Vallejo-Torres</Author><Year>2014</Year><IDText>Measuring current and future cost of skin cancer in England</IDText><DisplayText><style face="superscript">3</style></DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>2014</year></dates><keywords><keyword>Cost of Illness</keyword><keyword>England</keyword><keyword>Forecasting</keyword><keyword>Health Care Costs</keyword><keyword>Humans</keyword><keyword>Skin Neoplasms</keyword><keyword>burden of disease</keyword><keyword>cost</keyword><keyword>cost of illness</keyword><keyword>skin cancer</keyword></keywords><urls><related-urls><url> current and future cost of skin cancer in England</title><secondary-title>J Public Health (Oxf)</secondary-title></titles><pages>140-8</pages><number>1</number><contributors><authors><author>Vallejo-Torres, L.</author><author>Morris, S.</author><author>Kinge, J. M.</author><author>Poirier, V.</author><author>Verne, J.</author></authors></contributors><edition>2013/04/03</edition><language>eng</language><added-date format="utc">1571595342</added-date><ref-type name="Journal Article">17</ref-type><rec-number>234</rec-number><last-updated-date format="utc">1571595342</last-updated-date><accession-num>23554510</accession-num><electronic-resource-num>10.1093/pubmed/fdt032</electronic-resource-num><volume>36</volume></record></Cite></EndNote>3. The reported incidence is rising (30% in the last decade), likely due to increased reporting and historic exposure to ultraviolet radiation. The mainstay of treatment for non-melanoma skin cancer is surgical excision with a ‘cuff’ of normal tissue, which allows examination of the histological subtype and accurate assessment of margins: excision confirms the tumours complete removal. The outcome is highly dependent upon achieving clear margins; just 1%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXNjYWw8L0F1dGhvcj48WWVhcj4xOTY4PC9ZZWFyPjxJ
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ADDIN EN.CITE.DATA 8, 9. It also has a role in the treatment of incompletely excised BCC and high-risk SCC as an adjunct to excision ADDIN EN.CITE <EndNote><Cite><Author>Geohas</Author><Year>1994</Year><IDText>Adjuvant radiotherapy after excision of cutaneous squamous cell carcinoma</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>1994</year></dates><keywords><keyword>Aged</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Combined Modality Therapy</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mohs Surgery</keyword><keyword>Prognosis</keyword><keyword>Skin Neoplasms</keyword><keyword>Thorax</keyword></keywords><urls><related-urls><url> radiotherapy after excision of cutaneous squamous cell carcinoma</title><secondary-title>J Am Acad Dermatol</secondary-title></titles><pages>633-6</pages><number>4</number><contributors><authors><author>Geohas, J.</author><author>Roholt, N. S.</author><author>Robinson, J. K.</author></authors></contributors><language>eng</language><added-date format="utc">1574350314</added-date><ref-type name="Journal Article">17</ref-type><rec-number>2665</rec-number><last-updated-date format="utc">1574350314</last-updated-date><accession-num>8157790</accession-num><electronic-resource-num>10.1016/s0190-9622(94)70073-7</electronic-resource-num><volume>30</volume></record></Cite></EndNote>10. In practice however, radiotherapy is rarely utilised for primary lesions as it does not allow examination of the margins to confirm clearance. In the UK, surgical excision of skin cancer is mainly performed in secondary care ADDIN EN.CITE <EndNote><Cite><Author>NHS</Author><Year>2013</Year><IDText>2013/14 NHS STANDARD CONTRACT FOR CANCER: SKIN (ADULT)</IDText><DisplayText><style face="superscript">11</style></DisplayText><record><urls><related-urls><url> NHS STANDARD CONTRACT FOR CANCER: SKIN (ADULT)</title></titles><contributors><authors><author>NHS England</author></authors></contributors><added-date format="utc">1571626685</added-date><ref-type name="Generic">13</ref-type><dates><year>2013</year></dates><rec-number>239</rec-number><last-updated-date format="utc">1571626716</last-updated-date></record></Cite></EndNote>11 where it is more cost effective ADDIN EN.CITE <EndNote><Cite><Author>George</Author><Year>2008</Year><IDText>A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial</IDText><DisplayText><style face="superscript">12</style></DisplayText><record><dates><pub-dates><date>May</date></pub-dates><year>2008</year></dates><keywords><keyword>Ambulatory Care</keyword><keyword>Elective Surgical Procedures</keyword><keyword>England</keyword><keyword>Female</keyword><keyword>Health Expenditures</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Medical Staff, Hospital</keyword><keyword>Middle Aged</keyword><keyword>Minor Surgical Procedures</keyword><keyword>Nails, Ingrown</keyword><keyword>Pain Measurement</keyword><keyword>Physicians, Family</keyword><keyword>Primary Health Care</keyword><keyword>Professional Competence</keyword><keyword>Prospective Studies</keyword><keyword>Quality of Health Care</keyword><keyword>Safety</keyword><keyword>Skin Diseases</keyword></keywords><urls><related-urls><url> prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial</title><secondary-title>Health Technol Assess</secondary-title></titles><pages>iii-iv, ix-38</pages><number>23</number><contributors><authors><author>George, S.</author><author>Pockney, P.</author><author>Primrose, J.</author><author>Smith, H.</author><author>Little, P.</author><author>Kinley, H.</author><author>Kneebone, R.</author><author>Lowy, A.</author><author>Leppard, B.</author><author>Jayatilleke, N.</author><author>McCabe, C.</author></authors></contributors><language>eng</language><added-date format="utc">1572032921</added-date><ref-type name="Journal Article">17</ref-type><rec-number>267</rec-number><last-updated-date format="utc">1572032921</last-updated-date><accession-num>18505669</accession-num><volume>12</volume></record></Cite></EndNote>12 and consequently makes up a significant proportion of the workload for Dermatology and Plastic Surgery. There is joint guidance from the National Institute for Health and Care Excellence (NICE) and the British Association of Dermatologists (BAD) on the treatment of skin cancer which includes the planned surgical marginsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Nb3RsZXk8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxJ
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ADDIN EN.CITE.DATA 8, 9. Previous Dermatology national audits Two UK national audits have been undertaken by Dermatology to establish the incomplete excision rate and complications from non-melanoma skin cancer. UK Dermatology consultants submitted 10 consecutive cases of non-micrographic excision from 135 centres. The first cycle in 2014 of 2739 lesions had an incomplete excision rate of 2.3% ADDIN EN.CITE <EndNote><Cite><Author>Keith</Author><Year>2017</Year><IDText>British Association of Dermatologists' national audit on nonmelanoma skin cancer excision, 2014</IDText><DisplayText><style face="superscript">13</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2017</year></dates><keywords><keyword>Clinical Audit</keyword><keyword>Dermatologic Surgical Procedures</keyword><keyword>Dermatology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>Melanoma</keyword><keyword>Neoplasm Seeding</keyword><keyword>Prevalence</keyword><keyword>Referral and Consultation</keyword><keyword>Skin Neoplasms</keyword><keyword>Societies, Medical</keyword><keyword>United Kingdom</keyword></keywords><urls><related-urls><url> Association of Dermatologists' national audit on nonmelanoma skin cancer excision, 2014</title><secondary-title>Clin Exp Dermatol</secondary-title></titles><pages>46-53</pages><number>1</number><contributors><authors><author>Keith, D. J.</author><author>de Berker, D. A.</author><author>Bray, A. P.</author><author>Cheung, S. T.</author><author>Brain, A.</author><author>Mohd Mustapa, M. F.</author></authors></contributors><language>eng</language><added-date format="utc">1571244524</added-date><ref-type name="Journal Article">17</ref-type><rec-number>224</rec-number><last-updated-date format="utc">1571244524</last-updated-date><accession-num>28028856</accession-num><electronic-resource-num>10.1111/ced.12990</electronic-resource-num><volume>42</volume></record></Cite></EndNote>13. A second cycle in 2016 of 3290 reported an incomplete rate of 3.0% ADDIN EN.CITE <EndNote><Cite><Author>Keith</Author><Year>2019</Year><IDText>British Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists</IDText><DisplayText><style face="superscript">14</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2019</year></dates><urls><related-urls><url> Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists</title><secondary-title>Clin Exp Dermatol</secondary-title></titles><contributors><authors><author>Keith, D. J.</author><author>Bray, A. P.</author><author>Brain, A.</author><author>Mohd Mustapa, M. F.</author><author>Barrett, H. E.</author><author>Lane, S.</author><author>Emmerich, M.</author><author>Jakes, A.</author><author>Barrett, P. D.</author><author>de Berker, D. A. R.</author></authors></contributors><edition>2019/07/02</edition><language>eng</language><added-date format="utc">1571244524</added-date><ref-type name="Journal Article">17</ref-type><rec-number>223</rec-number><last-updated-date format="utc">1571244524</last-updated-date><accession-num>31265150</accession-num><electronic-resource-num>10.1111/ced.14034</electronic-resource-num></record></Cite></EndNote>14. There were no audit changes instigated following the original audit. In the subsequent audit cycle, they recommended histopathologists include all core data items in their reports but no changes to Dermatologists practice. This data gave an insight into the ‘typical’ lesion a dermatologist might encounter and their approach; a suspected BCC on the head and neck (58%), of mean diameter of 11mm which is excised and closed directly (88%) and not followed up in secondary care PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWl0aDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PElE
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ADDIN EN.CITE.DATA 13, 14, 20, 21 in all bar one study where it was 100% ADDIN EN.CITE <EndNote><Cite><Author>Macbeth</Author><Year>2009</Year><IDText>Audit of incomplete excision rates of basal cell carcinoma: analysis of 1972 cases from four U.K. regions</IDText><DisplayText><style face="superscript">22</style></DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2009</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Clinical Competence</keyword><keyword>England</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Neoplasm, Residual</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> of incomplete excision rates of basal cell carcinoma: analysis of 1972 cases from four U.K. regions</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>710-2</pages><number>3</number><contributors><authors><author>Macbeth, A. E.</author><author>Torley, D.</author><author>Casie Chetty, N.</author><author>Hepburn, N.</author><author>Hussain, K.</author><author>Blasdale, C.</author><author>von der Werth, J.</author><author>Garioch, J. J.</author><author>Levell, N. J.</author></authors></contributors><edition>2009/07/03</edition><language>eng</language><added-date format="utc">1572013556</added-date><ref-type name="Journal Article">17</ref-type><rec-number>258</rec-number><last-updated-date format="utc">1572013556</last-updated-date><accession-num>19575756</accession-num><electronic-resource-num>10.1111/j.1365-2133.2009.09346.x</electronic-resource-num><volume>161</volume></record></Cite></EndNote>22 and GPs the least at between 30-50%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ud2lzdDwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PElE
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ADDIN EN.CITE.DATA 25, 27, 28.The size of the lesions affects the incomplete excision rate. One study on scalp BCC showed larger tumours were more often higher grade and more commonly had perineural invasion ADDIN EN.CITE <EndNote><Cite><Author>Cho</Author><Year>2016</Year><IDText>Scalp Basal Cell Carcinoma: Review of 2,202 Cases</IDText><DisplayText><style face="superscript">29</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2016</year></dates><keywords><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Invasiveness</keyword><keyword>Neoplasm, Residual</keyword><keyword>Retrospective Studies</keyword><keyword>Scalp</keyword><keyword>Sex Factors</keyword><keyword>Skin Neoplasms</keyword><keyword>South Australia</keyword></keywords><urls><related-urls><url> Basal Cell Carcinoma: Review of 2,202 Cases</title><secondary-title>Dermatol Surg</secondary-title></titles><pages>834-41</pages><number>7</number><contributors><authors><author>Cho, M.</author><author>Lee, J.</author><author>James, C. L.</author><author>Marshman, G.</author><author>Huilgol, S. C.</author></authors></contributors><language>eng</language><added-date format="utc">1572014245</added-date><ref-type name="Journal Article">17</ref-type><rec-number>264</rec-number><last-updated-date format="utc">1572014245</last-updated-date><accession-num>27243131</accession-num><electronic-resource-num>10.1097/DSS.0000000000000783</electronic-resource-num><volume>42</volume></record></Cite></EndNote>29. These factors increased their incomplete excision rate to 26% from 16% ADDIN EN.CITE <EndNote><Cite><Author>Cho</Author><Year>2016</Year><IDText>Scalp Basal Cell Carcinoma: Review of 2,202 Cases</IDText><DisplayText><style face="superscript">29</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2016</year></dates><keywords><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Invasiveness</keyword><keyword>Neoplasm, Residual</keyword><keyword>Retrospective Studies</keyword><keyword>Scalp</keyword><keyword>Sex Factors</keyword><keyword>Skin Neoplasms</keyword><keyword>South Australia</keyword></keywords><urls><related-urls><url> Basal Cell Carcinoma: Review of 2,202 Cases</title><secondary-title>Dermatol Surg</secondary-title></titles><pages>834-41</pages><number>7</number><contributors><authors><author>Cho, M.</author><author>Lee, J.</author><author>James, C. L.</author><author>Marshman, G.</author><author>Huilgol, S. C.</author></authors></contributors><language>eng</language><added-date format="utc">1572014245</added-date><ref-type name="Journal Article">17</ref-type><rec-number>264</rec-number><last-updated-date format="utc">1572014245</last-updated-date><accession-num>27243131</accession-num><electronic-resource-num>10.1097/DSS.0000000000000783</electronic-resource-num><volume>42</volume></record></Cite></EndNote>29. Larger tumours were more likely to be incompletely excised in another study ADDIN EN.CITE <EndNote><Cite><Author>Stolle</Author><Year>2013</Year><IDText>A single center retrospective study on 959 excisions of non-melanoma skin cancer in 2011</IDText><DisplayText><style face="superscript">19</style></DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>2013</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Extremities</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm, Residual</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Retrospective Studies</keyword><keyword>Scalp</keyword><keyword>Skin Neoplasms</keyword><keyword>Torso</keyword><keyword>Tumor Burden</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> single center retrospective study on 959 excisions of non-melanoma skin cancer in 2011</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>1630-2</pages><number>11</number><contributors><authors><author>Stolle, L. 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ADDIN EN.CITE.DATA 15, 27. All three observations can simultaneously be true if the case mix is sufficiently different, with units where juniors are excising incompletely more may be working on cases beyond their capabilities and in units where the rate is lower may be because they are not being challenged or trusted enough with cases they are well capable of. Specific histological types of BCC (infiltrative and morphoeic) are known to be higher risk for incomplete excisionPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZWxmZXI8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxJ
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ADDIN EN.CITE.DATA 13, 14. The complication rates were rarely reported, however was 4.4% ADDIN EN.CITE <EndNote><Cite><Author>Malik</Author><Year>2010</Year><IDText>Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit</IDText><DisplayText><style face="superscript">15</style></DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2010</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Cheek</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nose Neoplasms</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Outcome</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>2057-63</pages><number>12</number><contributors><authors><author>Malik, V.</author><author>Goh, K. S.</author><author>Leong, S.</author><author>Tan, A.</author><author>Downey, D.</author><author>O'Donovan, D.</author></authors></contributors><edition>2010/03/11</edition><language>eng</language><added-date format="utc">1571990457</added-date><ref-type name="Journal Article">17</ref-type><rec-number>245</rec-number><last-updated-date format="utc">1571990457</last-updated-date><accession-num>20226750</accession-num><electronic-resource-num>10.1016/j.bjps.2010.01.016</electronic-resource-num><volume>63</volume></record></Cite></EndNote>15 in one Plastic Surgery unit and 3.0-3.4%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWl0aDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PElE
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ADDIN EN.CITE.DATA 13, 14 in UK Dermatologists. Finally, three studies have directly compared incomplete excision rates between different practitioners who excised skin cancer. These all reported Dermatology (0-14.2%PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbGVpc2NoZXI8L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFy
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ADDIN EN.CITE.DATA 21, 34). Studies often concluded this difference was due to increased amount of training time of Dermatologists spend on skin cancer. Pre-operative selection may play a role in reducing Dermatologists incomplete margin rate. They generally have the greatest access to Moh’s micrographic surgery, removing the most challenging and highest risk tumours from their caseload. Indeed in one study where Moh’s micrographic surgery was being used by dermatology, they unsurprisingly reported a 0% incomplete margin ADDIN EN.CITE <EndNote><Cite><Author>Salmon</Author><Year>2010</Year><IDText>Surgical excision of skin cancer: the importance of training</IDText><DisplayText><style face="superscript">21</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2010</year></dates><keywords><keyword>Ambulatory Surgical Procedures</keyword><keyword>Clinical Competence</keyword><keyword>Dermatology</keyword><keyword>Family Practice</keyword><keyword>Humans</keyword><keyword>Logistic Models</keyword><keyword>New Zealand</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Specialization</keyword></keywords><urls><related-urls><url> excision of skin cancer: the importance of training</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>117-22</pages><number>1</number><contributors><authors><author>Salmon, P.</author><author>Mortimer, N.</author><author>Rademaker, M.</author><author>Adams, L.</author><author>Stanway, A.</author><author>Hill, S.</author></authors></contributors><edition>2009/10/10</edition><language>eng</language><added-date format="utc">1571946122</added-date><ref-type name="Journal Article">17</ref-type><rec-number>243</rec-number><last-updated-date format="utc">1571946122</last-updated-date><accession-num>19818068</accession-num><electronic-resource-num>10.1111/j.1365-2133.2009.09548.x</electronic-resource-num><volume>162</volume></record></Cite></EndNote>21. There is a potential for a conflict of interest in terms of reporting one’s own incomplete excision rate which may affect funding from national bodies or cause patients to seek a different specialist in a private system. While there is nothing to doubt the integrity of the above published data, there may be a publication or selection bias, where authors consciously or subconsciously wish to publish data which places their own unit in the best light and are less forthcoming on a ‘bad’ audit cycle. Role of antibiotics in ulcerated lesionsLittle is known about the use of prophylactic antibiotics in the surgical excision of non-melanoma skin cancer. Certain lesion characteristics, such as ulceration, have previously been reported as independent risk factors for post-operative wound infection ADDIN EN.CITE <EndNote><Cite><Author>Penington</Author><Year>2010</Year><IDText>Ulceration and antihypertensive use are risk factors for infection after skin lesion excision</IDText><DisplayText><style face="superscript">35</style></DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2010</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Antihypertensive Agents</keyword><keyword>Australia</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Hypertension</keyword><keyword>Incidence</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>Risk Factors</keyword><keyword>Skin Neoplasms</keyword><keyword>Skin Ulcer</keyword><keyword>Surgical Wound Infection</keyword></keywords><urls><related-urls><url> and antihypertensive use are risk factors for infection after skin lesion excision</title><secondary-title>ANZ J Surg</secondary-title></titles><pages>642-5</pages><number>9</number><contributors><authors><author>Penington, A.</author></authors></contributors><language>eng</language><added-date format="utc">1574351559</added-date><ref-type name="Journal Article">17</ref-type><rec-number>2667</rec-number><last-updated-date format="utc">1574351559</last-updated-date><accession-num>20840409</accession-num><electronic-resource-num>10.1111/j.1445-2197.2010.05344.x</electronic-resource-num><volume>80</volume></record></Cite></EndNote>35. Despite this, a recent review of 4 RCTs on the use of prophylactic antibiotics in ulcerated BCC/SCC found a lack of high-quality evidence for their benefit ADDIN EN.CITE <EndNote><Cite><Author>Chan</Author><Year>2018</Year><IDText>Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic</IDText><DisplayText><style face="superscript">36</style></DisplayText><record><dates><pub-dates><date>02</date></pub-dates><year>2018</year></dates><keywords><keyword>Administration, Oral</keyword><keyword>Administration, Topical</keyword><keyword>Anti-Bacterial Agents</keyword><keyword>Antibiotic Prophylaxis</keyword><keyword>Humans</keyword><keyword>Injections, Intralesional</keyword><keyword>Intraoperative Care</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Risk Factors</keyword><keyword>Skin Neoplasms</keyword><keyword>Skin Ulcer</keyword><keyword>Surgical Wound Infection</keyword></keywords><urls><related-urls><url> perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>394-399</pages><number>2</number><contributors><authors><author>Chan, S. A.</author><author>Wernham, A. G. H.</author><author>Stembridge, N.</author><author>Harper, N.</author><author>Verykiou, S.</author><author>Fremlin, G. A.</author><author>Abbott, R. A.</author><author>Matin, R. N.</author></authors></contributors><edition>2018/01/18</edition><language>eng</language><added-date format="utc">1574351395</added-date><ref-type name="Journal Article">17</ref-type><rec-number>2666</rec-number><last-updated-date format="utc">1574351395</last-updated-date><accession-num>29193009</accession-num><electronic-resource-num>10.1111/bjd.16157</electronic-resource-num><volume>178</volume></record></Cite></EndNote>36. Author,Year,CountryType of study,Years of data collectionOperatorsNumber of lesionsIncomplete excision rate (%)Kumar et al. 2000, UK ADDIN EN.CITE <EndNote><Cite><Author>Kumar</Author><Year>2000</Year><IDText>Incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit</IDText><DisplayText><style face="superscript">31</style></DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2000</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Distribution</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Child</keyword><keyword>Clinical Competence</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Medical Audit</keyword><keyword>Medical Staff, Hospital</keyword><keyword>Middle Aged</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Sex Distribution</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit</title><secondary-title>Br J Plast Surg</secondary-title></titles><pages>563-6</pages><number>7</number><contributors><authors><author>Kumar, P.</author><author>Orton, C. I.</author><author>McWilliam, L. J.</author><author>Watson, S.</author></authors></contributors><language>eng</language><added-date format="utc">1571257191</added-date><ref-type name="Journal Article">17</ref-type><rec-number>230</rec-number><last-updated-date format="utc">1571257191</last-updated-date><accession-num>11000071</accession-num><electronic-resource-num>10.1054/bjps.2000.3394</electronic-resource-num><volume>53</volume></record></Cite></EndNote>31Single centre2 yearsPlastics879 BCC4.7%Fleischer et al. 2001, USAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbGVpc2NoZXI8L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFy
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ADDIN EN.CITE.DATA 20Multi centreBetween 1 year and 5.5 years depending on centrePlastics1 459 BCC27.6%ENT46.9%Dermatology14.2%General surgery 17.9%Hallock et al. 2001, USA ADDIN EN.CITE <EndNote><Cite><Author>Hallock</Author><Year>2001</Year><IDText>A prospective study of the accuracy of the surgeon's diagnosis and significance of positive margins in nonmelanoma skin cancers</IDText><DisplayText><style face="superscript">37</style></DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>2001</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Dermatologic Surgical Procedures</keyword><keyword>Diagnosis, Differential</keyword><keyword>Facial Neoplasms</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Neoplasm Invasiveness</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Neoplasm Staging</keyword><keyword>Neoplasm, Residual</keyword><keyword>Precancerous Conditions</keyword><keyword>Prospective Studies</keyword><keyword>Reoperation</keyword><keyword>Skin</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> prospective study of the accuracy of the surgeon's diagnosis and significance of positive margins in nonmelanoma skin cancers</title><secondary-title>Plast Reconstr Surg</secondary-title></titles><pages>942-7</pages><number>4</number><contributors><authors><author>Hallock, G. G.</author><author>Lutz, D. A.</author></authors></contributors><language>eng</language><added-date format="utc">1572012837</added-date><ref-type name="Journal Article">17</ref-type><rec-number>248</rec-number><last-updated-date format="utc">1572012837</last-updated-date><accession-num>11252086</accession-num><electronic-resource-num>10.1097/00006534-200104010-00006</electronic-resource-num><volume>107</volume></record></Cite></EndNote>37Single centre7.5 yearsPlastics309 BCC16.2%106 SCC14.2%Dieu et al. 2002, Australia ADDIN EN.CITE <EndNote><Cite><Author>Dieu</Author><Year>2002</Year><IDText>Incomplete excision of basal cell carcinomas: a retrospective audit</IDText><DisplayText><style face="superscript">25</style></DisplayText><record><dates><pub-dates><date>Mar</date></pub-dates><year>2002</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Australia</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Medical Audit</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Reoperation</keyword><keyword>Reproducibility of Results</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Failure</keyword></keywords><urls><related-urls><url> excision of basal cell carcinomas: a retrospective audit</title><secondary-title>ANZ J Surg</secondary-title></titles><pages>219-21</pages><number>3</number><contributors><authors><author>Dieu, T.</author><author>Macleod, A. M.</author></authors></contributors><language>eng</language><added-date format="utc">1572012895</added-date><ref-type name="Journal Article">17</ref-type><rec-number>249</rec-number><last-updated-date format="utc">1572012895</last-updated-date><accession-num>12071456</accession-num><volume>72</volume></record></Cite></EndNote>25Single centre3.5 yearsPlastics3 558 BCC6.3%Kumar et al. 2002, UK ADDIN EN.CITE <EndNote><Cite><Author>Kumar</Author><Year>2002</Year><IDText>Incomplete excision of basal cell carcinoma: a prospective multicentre audit</IDText><DisplayText><style face="superscript">32</style></DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2002</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Distribution</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Clinical Competence</keyword><keyword>Confounding Factors (Epidemiology)</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Medical Staff, Hospital</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Recurrence</keyword><keyword>Sex Distribution</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> excision of basal cell carcinoma: a prospective multicentre audit</title><secondary-title>Br J Plast Surg</secondary-title></titles><pages>616-22</pages><number>8</number><contributors><authors><author>Kumar, P.</author><author>Watson, S.</author><author>Brain, A. N.</author><author>Davenport, P. J.</author><author>McWilliam, L. J.</author><author>Banerjee, S. S.</author><author>Bisset, D. L.</author></authors></contributors><language>eng</language><added-date format="utc">1571255755</added-date><ref-type name="Journal Article">17</ref-type><rec-number>225</rec-number><last-updated-date format="utc">1571255755</last-updated-date><accession-num>12550113</accession-num><electronic-resource-num>10.1054/bjps.2002.3948</electronic-resource-num><volume>55</volume></record></Cite></EndNote>32Regional 1 yearPlastics757 BCC4.5%Timmons et al.2002, UK ADDIN EN.CITE <EndNote><Cite><Author>Timmons</Author><Year>2002</Year><IDText>Complete excision of basal cell carcinomas</IDText><DisplayText><style face="superscript">18</style></DisplayText><record><dates><pub-dates><date>Jun</date></pub-dates><year>2002</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> excision of basal cell carcinomas</title><secondary-title>Br J Plast Surg</secondary-title></titles><pages>362</pages><number>4</number><contributors><authors><author>Timmons, M. J.</author><author>Hessel, K. C.</author><author>Kranidhiotis, N. M.</author></authors></contributors><language>eng</language><added-date format="utc">1572012933</added-date><ref-type name="Journal Article">17</ref-type><rec-number>250</rec-number><last-updated-date format="utc">1572012933</last-updated-date><accession-num>12160548</accession-num><electronic-resource-num>10.1054/bjps.2002.3849</electronic-resource-num><volume>55</volume></record></Cite></EndNote>18Single centre1 yearPlastics557 BCC3.8%Hussain et al. 2003, Ireland ADDIN EN.CITE <EndNote><Cite><Author>Hussain</Author><Year>2003</Year><IDText>The incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit</IDText><DisplayText><style face="superscript">38</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2003</year></dates><keywords><keyword>Adult</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Ireland</keyword><keyword>Male</keyword><keyword>Medical Audit</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Time Factors</keyword></keywords><urls><related-urls><url> incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit</title><secondary-title>Ir Med J</secondary-title></titles><pages>18-20</pages><number>1</number><contributors><authors><author>Hussain, M.</author><author>Earley, M. J.</author></authors></contributors><language>eng</language><added-date format="utc">1572012977</added-date><ref-type name="Journal Article">17</ref-type><rec-number>251</rec-number><last-updated-date format="utc">1572012977</last-updated-date><accession-num>12617437</accession-num><volume>96</volume></record></Cite></EndNote>38Single centre1 yearPlastics126 BCC7.9%Bogdanov-Berzovsky et al. 2004, Israel ADDIN EN.CITE <EndNote><Cite><Author>Bogdanov-Berezovsky</Author><Year>2004</Year><IDText>Risk factors for incomplete excision of basal cell carcinomas</IDText><DisplayText><style face="superscript">28</style></DisplayText><record><keywords><keyword>Aged</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Basosquamous</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Facial Neoplasms</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Risk Factors</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> factors for incomplete excision of basal cell carcinomas</title><secondary-title>Acta Derm Venereol</secondary-title></titles><pages>44-7</pages><number>1</number><contributors><authors><author>Bogdanov-Berezovsky, A.</author><author>Cohen, A. D.</author><author>Glesinger, R.</author><author>Cagnano, E.</author><author>Krieger, Y.</author><author>Rosenberg, L.</author></authors></contributors><language>eng</language><added-date format="utc">1572013107</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2004</year></dates><rec-number>252</rec-number><last-updated-date format="utc">1572013107</last-updated-date><accession-num>15040477</accession-num><electronic-resource-num>10.1080/00015550310020585</electronic-resource-num><volume>84</volume></record></Cite></EndNote>28Single centre4 yearsPlastics1 478 BCC10.8%Talbot et al.2004, New Zealand ADDIN EN.CITE <EndNote><Cite><Author>Talbot</Author><Year>2004</Year><IDText>Incomplete primary excision of cutaneous basal and squamous cell carcinomas in the Bay of Plenty</IDText><DisplayText><style face="superscript">27</style></DisplayText><record><dates><pub-dates><date>Apr</date></pub-dates><year>2004</year></dates><keywords><keyword>Aged</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Basosquamous</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Educational Status</keyword><keyword>Family Practice</keyword><keyword>Female</keyword><keyword>General Surgery</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm, Residual</keyword><keyword>New Zealand</keyword><keyword>Retrospective Studies</keyword><keyword>Sex Factors</keyword><keyword>Skin</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> primary excision of cutaneous basal and squamous cell carcinomas in the Bay of Plenty</title><secondary-title>N Z Med J</secondary-title></titles><pages>U848</pages><number>1192</number><contributors><authors><author>Talbot, S.</author><author>Hitchcock, B.</author></authors></contributors><edition>2004/04/23</edition><language>eng</language><added-date format="utc">1572013162</added-date><ref-type name="Journal Article">17</ref-type><rec-number>253</rec-number><last-updated-date format="utc">1572013162</last-updated-date><accession-num>15107870</accession-num><volume>117</volume></record></Cite></EndNote>27Regional0.5 years Plastics818 NMSC11.3%General Practice1003 NMSC16%Wilson et al. 2004, UK ADDIN EN.CITE <EndNote><Cite><Author>Wilson</Author><Year>2004</Year><IDText>Surgical management of incompletely excised basal cell carcinomas of the head and neck</IDText><DisplayText><style face="superscript">26</style></DisplayText><record><dates><pub-dates><date>Aug</date></pub-dates><year>2004</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Cohort Studies</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Neoplasm, Residual</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Risk Factors</keyword></keywords><urls><related-urls><url> management of incompletely excised basal cell carcinomas of the head and neck</title><secondary-title>Br J Oral Maxillofac Surg</secondary-title></titles><pages>311-4</pages><number>4</number><contributors><authors><author>Wilson, A. W.</author><author>Howsam, G.</author><author>Santhanam, V.</author><author>Macpherson, D.</author><author>Grant, J.</author><author>Pratt, C. A.</author><author>Townend, J. V.</author></authors></contributors><language>eng</language><added-date format="utc">1572013254</added-date><ref-type name="Journal Article">17</ref-type><rec-number>254</rec-number><last-updated-date format="utc">1572013254</last-updated-date><accession-num>15225948</accession-num><electronic-resource-num>10.1016/j.bjoms.2004.02.030</electronic-resource-num><volume>42</volume></record></Cite></EndNote>26Regional10 yearsMaxillofacial3 795 BCC6.2%Deo et al.2005, India ADDIN EN.CITE <EndNote><Cite><Author>Deo</Author><Year>2005</Year><IDText>Surgical management of skin cancers: experience from a regional cancer centre in North India</IDText><DisplayText><style face="superscript">39</style></DisplayText><record><dates><pub-dates><date>2005 Jul-Sep</date></pub-dates><year>2005</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Databases as Topic</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>India</keyword><keyword>Male</keyword><keyword>Medical Audit</keyword><keyword>Middle Aged</keyword><keyword>Oncology Service, Hospital</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Utilization Review</keyword></keywords><urls><related-urls><url> management of skin cancers: experience from a regional cancer centre in North India</title><secondary-title>Indian J Cancer</secondary-title></titles><pages>145-50</pages><number>3</number><contributors><authors><author>Deo, S. V.</author><author>Hazarika, S.</author><author>Shukla, N. K.</author><author>Kumar, S.</author><author>Kar, M.</author><author>Samaiya, A.</author></authors></contributors><language>eng</language><added-date format="utc">1572013323</added-date><ref-type name="Journal Article">17</ref-type><rec-number>255</rec-number><last-updated-date format="utc">1572013323</last-updated-date><accession-num>16276015</accession-num><volume>42</volume></record></Cite></EndNote>39Single centre7 yearsSurgical oncology 14 BCC0%43 SCC0%Griffiths et al. 2007, UK ADDIN EN.CITE <EndNote><Cite><Author>Griffiths</Author><Year>2007</Year><IDText>Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?</IDText><DisplayText><style face="superscript">16</style></DisplayText><record><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Outcome</keyword></keywords><urls><related-urls><url> cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper?</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>41-7</pages><number>1</number><contributors><authors><author>Griffiths, R. W.</author><author>Suvarna, S. K.</author><author>Stone, J.</author></authors></contributors><edition>2006/09/01</edition><language>eng</language><added-date format="utc">1571999638</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2007</year></dates><rec-number>246</rec-number><last-updated-date format="utc">1571999638</last-updated-date><accession-num>17126265</accession-num><electronic-resource-num>10.1016/j.bjps.2006.06.009</electronic-resource-num><volume>60</volume></record></Cite></EndNote>16Single centre5 yearsPlastics1 539 BCC8.4%Dhepnorrarat et al.2009, Australia ADDIN EN.CITE <EndNote><Cite><Author>Dhepnorrarat</Author><Year>2009</Year><IDText>Incompletely excised skin cancer rates: a prospective study of 31,731 skin cancer excisions by the Western Australian Society of Plastic Surgeons</IDText><DisplayText><style face="superscript">40</style></DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2009</year></dates><keywords><keyword>Australia</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Skin Neoplasms</keyword><keyword>Surgery, Plastic</keyword></keywords><urls><related-urls><url> excised skin cancer rates: a prospective study of 31,731 skin cancer excisions by the Western Australian Society of Plastic Surgeons</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>1281-5</pages><number>10</number><contributors><authors><author>Dhepnorrarat, R. C.</author><author>Lee, M. A.</author><author>Mountain, J. A.</author></authors></contributors><edition>2008/08/08</edition><language>eng</language><added-date format="utc">1572013480</added-date><ref-type name="Journal Article">17</ref-type><rec-number>257</rec-number><last-updated-date format="utc">1572013480</last-updated-date><accession-num>18691954</accession-num><electronic-resource-num>10.1016/j.bjps.2008.04.028</electronic-resource-num><volume>62</volume></record></Cite></EndNote>40Regional7 yearsPlastics21 677 BCC4.0%8 355 SCC3.7%Haque Hussain et al.2009, UK ADDIN EN.CITE <EndNote><Cite><Author>Haque Hussain</Author><Year>2009</Year><IDText>Managing squamous cell carcinomas: audit on the mode of referral and adequacy of surgical excision</IDText><DisplayText><style face="superscript">41</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2009</year></dates><keywords><keyword>Carcinoma, Squamous Cell</keyword><keyword>Clinical Audit</keyword><keyword>Family Practice</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Referral and Consultation</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> squamous cell carcinomas: audit on the mode of referral and adequacy of surgical excision</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>224-5</pages><number>1</number><contributors><authors><author>Haque Hussain, S. S.</author><author>Shams, N.</author><author>Garioch, J. J.</author></authors></contributors><edition>2008/11/28</edition><language>eng</language><added-date format="utc">1572298311</added-date><ref-type name="Journal Article">17</ref-type><rec-number>271</rec-number><last-updated-date format="utc">1572298311</last-updated-date><accession-num>19067692</accession-num><electronic-resource-num>10.1111/j.1365-2133.2008.08942.x</electronic-resource-num><volume>160</volume></record></Cite></EndNote>41Single centre0.5 yearsDermatology80 SCC7.5%Plastics8.3%General Practice15 SCC43%Macbeth et al. 2009, UK ADDIN EN.CITE <EndNote><Cite><Author>Macbeth</Author><Year>2009</Year><IDText>Audit of incomplete excision rates of basal cell carcinoma: analysis of 1972 cases from four U.K. regions</IDText><DisplayText><style face="superscript">22</style></DisplayText><record><dates><pub-dates><date>Sep</date></pub-dates><year>2009</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Clinical Competence</keyword><keyword>England</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Neoplasm, Residual</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> of incomplete excision rates of basal cell carcinoma: analysis of 1972 cases from four U.K. regions</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>710-2</pages><number>3</number><contributors><authors><author>Macbeth, A. E.</author><author>Torley, D.</author><author>Casie Chetty, N.</author><author>Hepburn, N.</author><author>Hussain, K.</author><author>Blasdale, C.</author><author>von der Werth, J.</author><author>Garioch, J. J.</author><author>Levell, N. J.</author></authors></contributors><edition>2009/07/03</edition><language>eng</language><added-date format="utc">1572013556</added-date><ref-type name="Journal Article">17</ref-type><rec-number>258</rec-number><last-updated-date format="utc">1572013556</last-updated-date><accession-num>19575756</accession-num><electronic-resource-num>10.1111/j.1365-2133.2009.09346.x</electronic-resource-num><volume>161</volume></record></Cite></EndNote>224 regionsBetween 1 month - 1 year per region. Totalling 3.25 years Dermatology955 BCC10%General Practice254 BCC33%Twist.2009, UK ADDIN EN.CITE <EndNote><Cite><Author>Twist</Author><Year>2009</Year><IDText>Rate of incomplete excision of basal cell carcinomas by General Practitioners with Special Interest</IDText><DisplayText><style face="superscript">23</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2009</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Dermatology</keyword><keyword>Family Practice</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Neoplasm, Residual</keyword><keyword>Skin Neoplasms</keyword><keyword>Specialization</keyword><keyword>Wales</keyword></keywords><urls><related-urls><url> of incomplete excision of basal cell carcinomas by General Practitioners with Special Interest</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>187</pages><number>1</number><contributors><authors><author>Twist, M.</author></authors></contributors><edition>2009/03/26</edition><language>eng</language><added-date format="utc">1572013772</added-date><ref-type name="Journal Article">17</ref-type><rec-number>259</rec-number><last-updated-date format="utc">1572013772</last-updated-date><accession-num>19416253</accession-num><electronic-resource-num>10.1111/j.1365-2133.2009.09129.x</electronic-resource-num><volume>161</volume></record></Cite></EndNote>23Single centre3 yearsGeneral Practice (special interest)124 BCC1.6%Malik et al. 2010, Ireland ADDIN EN.CITE <EndNote><Cite><Author>Malik</Author><Year>2010</Year><IDText>Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit</IDText><DisplayText><style face="superscript">15</style></DisplayText><record><dates><pub-dates><date>Dec</date></pub-dates><year>2010</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Cheek</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nose Neoplasms</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Outcome</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>2057-63</pages><number>12</number><contributors><authors><author>Malik, V.</author><author>Goh, K. S.</author><author>Leong, S.</author><author>Tan, A.</author><author>Downey, D.</author><author>O'Donovan, D.</author></authors></contributors><edition>2010/03/11</edition><language>eng</language><added-date format="utc">1571990457</added-date><ref-type name="Journal Article">17</ref-type><rec-number>245</rec-number><last-updated-date format="utc">1571990457</last-updated-date><accession-num>20226750</accession-num><electronic-resource-num>10.1016/j.bjps.2010.01.016</electronic-resource-num><volume>63</volume></record></Cite></EndNote>15Single centre5 yearsPlastics1 832 BCC14%Salmon et al.2010, New Zealand ADDIN EN.CITE <EndNote><Cite><Author>Salmon</Author><Year>2010</Year><IDText>Surgical excision of skin cancer: the importance of training</IDText><DisplayText><style face="superscript">21</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2010</year></dates><keywords><keyword>Ambulatory Surgical Procedures</keyword><keyword>Clinical Competence</keyword><keyword>Dermatology</keyword><keyword>Family Practice</keyword><keyword>Humans</keyword><keyword>Logistic Models</keyword><keyword>New Zealand</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Specialization</keyword></keywords><urls><related-urls><url> excision of skin cancer: the importance of training</title><secondary-title>Br J Dermatol</secondary-title></titles><pages>117-22</pages><number>1</number><contributors><authors><author>Salmon, P.</author><author>Mortimer, N.</author><author>Rademaker, M.</author><author>Adams, L.</author><author>Stanway, A.</author><author>Hill, S.</author></authors></contributors><edition>2009/10/10</edition><language>eng</language><added-date format="utc">1571946122</added-date><ref-type name="Journal Article">17</ref-type><rec-number>243</rec-number><last-updated-date format="utc">1571946122</last-updated-date><accession-num>19818068</accession-num><electronic-resource-num>10.1111/j.1365-2133.2009.09548.x</electronic-resource-num><volume>162</volume></record></Cite></EndNote>21Regional0.3 years Dermatology743 BCC181 SCC0% (included Moh’s)*ENT, Ophthalmology, Gen. surgeons 20%*General Practice23%*General Practice (special interest)21.5%*Seretis et al.2010, Greece ADDIN EN.CITE <EndNote><Cite><Author>Seretis</Author><Year>2010</Year><IDText>Epidemiology of surgical treatment of nonmelanoma skin cancer of the head and neck in Greece</IDText><DisplayText><style face="superscript">42</style></DisplayText><record><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Female</keyword><keyword>Greece</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword></keywords><urls><related-urls><url> of surgical treatment of nonmelanoma skin cancer of the head and neck in Greece</title><secondary-title>Dermatol Surg</secondary-title></titles><pages>15-22</pages><number>1</number><contributors><authors><author>Seretis, K.</author><author>Thomaidis, V.</author><author>Karpouzis, A.</author><author>Tamiolakis, D.</author><author>Tsamis, I.</author></authors></contributors><edition>2009/11/13</edition><language>eng</language><added-date format="utc">1571258214</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2010</year></dates><rec-number>232</rec-number><last-updated-date format="utc">1571258214</last-updated-date><accession-num>19912277</accession-num><electronic-resource-num>10.1111/j.1524-4725.2009.01379.x</electronic-resource-num><volume>36</volume></record></Cite></EndNote>42Single centre2 yearsMaxillofacial 125 BCC3.3%54 SCC5.8%Delaney et al.2012, UK ADDIN EN.CITE <EndNote><Cite><Author>Delaney</Author><Year>2012</Year><IDText>Excising squamous cell carcinomas: comparing the performance of GPs, hospital skin specialists and other hospital specialists</IDText><DisplayText><style face="superscript">43</style></DisplayText><record><dates><pub-dates><date>Oct</date></pub-dates><year>2012</year></dates><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Clinical Competence</keyword><keyword>Dermatology</keyword><keyword>Female</keyword><keyword>General Practice</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Medical Staff, Hospital</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Surgery, Plastic</keyword></keywords><urls><related-urls><url> squamous cell carcinomas: comparing the performance of GPs, hospital skin specialists and other hospital specialists</title><secondary-title>Fam Pract</secondary-title></titles><pages>541-6</pages><number>5</number><contributors><authors><author>Delaney, E. K.</author><author>Duckworth, L.</author><author>Thompson, W. D.</author><author>Lee, A. J.</author><author>Murchie, P.</author></authors></contributors><edition>2012/02/09</edition><language>eng</language><added-date format="utc">1572298998</added-date><ref-type name="Journal Article">17</ref-type><rec-number>272</rec-number><last-updated-date format="utc">1572298998</last-updated-date><accession-num>22321614</accession-num><electronic-resource-num>10.1093/fampra/cms007</electronic-resource-num><volume>29</volume></record></Cite></EndNote>43Regional1 yearDermatology72 SCC13.9%Plastics443 SCC12.9%General Practice207 SCC14.5%Stolle et al.2013, Denmark ADDIN EN.CITE <EndNote><Cite><Author>Stolle</Author><Year>2013</Year><IDText>A single center retrospective study on 959 excisions of non-melanoma skin cancer in 2011</IDText><DisplayText><style face="superscript">19</style></DisplayText><record><dates><pub-dates><date>Nov</date></pub-dates><year>2013</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Extremities</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Hospitalization</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm, Residual</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Retrospective Studies</keyword><keyword>Scalp</keyword><keyword>Skin Neoplasms</keyword><keyword>Torso</keyword><keyword>Tumor Burden</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> single center retrospective study on 959 excisions of non-melanoma skin cancer in 2011</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><pages>1630-2</pages><number>11</number><contributors><authors><author>Stolle, L. B.</author><author>Kjerkegaard, U. K.</author></authors></contributors><edition>2013/06/14</edition><language>eng</language><added-date format="utc">1571257915</added-date><ref-type name="Journal Article">17</ref-type><rec-number>231</rec-number><last-updated-date format="utc">1571257915</last-updated-date><accession-num>23751973</accession-num><electronic-resource-num>10.1016/j.bjps.2013.05.021</electronic-resource-num><volume>66</volume></record></Cite></EndNote>19Single centre1 year Plastics616 BCC9.6%179 SCCRobinson et al. 2015, UK ADDIN EN.CITE <EndNote><Cite><Author>Robinson</Author><Year>2015</Year><IDText>Histopathological variation of incompletely excised basal cell carcinoma's and the variation with the grade of surgeon - implications for revalidation</IDText><DisplayText><style face="superscript">24</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2015</year></dates><keywords><keyword>Carcinoma, Basal Cell</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Medical Audit</keyword><keyword>Medical Staff, Hospital</keyword><keyword>Neoplasm, Residual</keyword><keyword>Northern Ireland</keyword><keyword>Reoperation</keyword><keyword>Retrospective Studies</keyword><keyword>Skin Neoplasms</keyword><keyword>Surgery, Plastic</keyword><keyword>Basal Cell Carcinoma</keyword><keyword>Revalidation</keyword><keyword>Surgical outcomes</keyword></keywords><urls><related-urls><url> variation of incompletely excised basal cell carcinoma's and the variation with the grade of surgeon - implications for revalidation</title><secondary-title>Eur J Surg Oncol</secondary-title></titles><pages>165-8</pages><number>1</number><contributors><authors><author>Robinson, A. J.</author><author>Walsh, M.</author><author>Hill, C.</author></authors></contributors><edition>2014/11/06</edition><language>eng</language><added-date format="utc">1572014211</added-date><ref-type name="Journal Article">17</ref-type><rec-number>263</rec-number><last-updated-date format="utc">1572014211</last-updated-date><accession-num>25468457</accession-num><electronic-resource-num>10.1016/j.ejso.2014.10.059</electronic-resource-num><volume>41</volume></record></Cite></EndNote>24Single centre1 year Plastics392 BCC4.8%Cho et al.2016, Australia ADDIN EN.CITE <EndNote><Cite><Author>Cho</Author><Year>2016</Year><IDText>Scalp Basal Cell Carcinoma: Review of 2,202 Cases</IDText><DisplayText><style face="superscript">29</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2016</year></dates><keywords><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Invasiveness</keyword><keyword>Neoplasm, Residual</keyword><keyword>Retrospective Studies</keyword><keyword>Scalp</keyword><keyword>Sex Factors</keyword><keyword>Skin Neoplasms</keyword><keyword>South Australia</keyword></keywords><urls><related-urls><url> Basal Cell Carcinoma: Review of 2,202 Cases</title><secondary-title>Dermatol Surg</secondary-title></titles><pages>834-41</pages><number>7</number><contributors><authors><author>Cho, M.</author><author>Lee, J.</author><author>James, C. L.</author><author>Marshman, G.</author><author>Huilgol, S. C.</author></authors></contributors><language>eng</language><added-date format="utc">1572014245</added-date><ref-type name="Journal Article">17</ref-type><rec-number>264</rec-number><last-updated-date format="utc">1572014245</last-updated-date><accession-num>27243131</accession-num><electronic-resource-num>10.1097/DSS.0000000000000783</electronic-resource-num><volume>42</volume></record></Cite></EndNote>29Regional 5 yearsDermatology2 202 scalp BCC16%Luz et al.2016, Brazil ADDIN EN.CITE <EndNote><Cite><Author>Luz</Author><Year>2016</Year><IDText>Analysis of effectiveness of a surgical treatment algorithm for basal cell carcinoma</IDText><DisplayText><style face="superscript">44</style></DisplayText><record><dates><pub-dates><date>2016 Nov-Dec</date></pub-dates><year>2016</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Algorithms</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Mohs Surgery</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Practice Guidelines as Topic</keyword><keyword>Reproducibility of Results</keyword><keyword>Risk Assessment</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Outcome</keyword><keyword>Tumor Burden</keyword></keywords><urls><related-urls><url> of effectiveness of a surgical treatment algorithm for basal cell carcinoma</title><secondary-title>An Bras Dermatol</secondary-title></titles><pages>726-731</pages><number>6</number><contributors><authors><author>Luz, F. B.</author><author>Ferron, C.</author><author>Cardoso, G. P.</author></authors></contributors><language>eng</language><added-date format="utc">1572174571</added-date><ref-type name="Journal Article">17</ref-type><rec-number>268</rec-number><last-updated-date format="utc">1572174571</last-updated-date><accession-num>28099591</accession-num><electronic-resource-num>10.1590/abd1806-4841.20165919</electronic-resource-num><volume>91</volume></record></Cite></EndNote>44Single team1.2 yearsDermatology881 BCC4.1%Keith et al.2017, UK ADDIN EN.CITE <EndNote><Cite><Author>Keith</Author><Year>2017</Year><IDText>British Association of Dermatologists' national audit on nonmelanoma skin cancer excision, 2014</IDText><DisplayText><style face="superscript">13</style></DisplayText><record><dates><pub-dates><date>Jan</date></pub-dates><year>2017</year></dates><keywords><keyword>Clinical Audit</keyword><keyword>Dermatologic Surgical Procedures</keyword><keyword>Dermatology</keyword><keyword>Diagnosis, Differential</keyword><keyword>Humans</keyword><keyword>Melanoma</keyword><keyword>Neoplasm Seeding</keyword><keyword>Prevalence</keyword><keyword>Referral and Consultation</keyword><keyword>Skin Neoplasms</keyword><keyword>Societies, Medical</keyword><keyword>United Kingdom</keyword></keywords><urls><related-urls><url> Association of Dermatologists' national audit on nonmelanoma skin cancer excision, 2014</title><secondary-title>Clin Exp Dermatol</secondary-title></titles><pages>46-53</pages><number>1</number><contributors><authors><author>Keith, D. J.</author><author>de Berker, D. A.</author><author>Bray, A. P.</author><author>Cheung, S. T.</author><author>Brain, A.</author><author>Mohd Mustapa, M. F.</author></authors></contributors><language>eng</language><added-date format="utc">1571244524</added-date><ref-type name="Journal Article">17</ref-type><rec-number>224</rec-number><last-updated-date format="utc">1571244524</last-updated-date><accession-num>28028856</accession-num><electronic-resource-num>10.1111/ced.12990</electronic-resource-num><volume>42</volume></record></Cite></EndNote>13National 0.4 yearsDermatology2 167 BCC2.3%491 SCCStathopoulos et al.2017, UK ADDIN EN.CITE <EndNote><Cite><Author>Stathopoulos</Author><Year>2017</Year><IDText>Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center</IDText><DisplayText><style face="superscript">30</style></DisplayText><record><dates><pub-dates><date>Feb</date></pub-dates><year>2017</year></dates><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Biopsy</keyword><keyword>Carcinoma, Basal Cell</keyword><keyword>Carcinoma, Squamous Cell</keyword><keyword>Diagnosis, Differential</keyword><keyword>Female</keyword><keyword>Head and Neck Neoplasms</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neoplasm Metastasis</keyword><keyword>Neoplasm Recurrence, Local</keyword><keyword>Predictive Value of Tests</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Skin Neoplasms</keyword><keyword>Treatment Outcome</keyword></keywords><urls><related-urls><url> and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center</title><secondary-title>Oral Surg Oral Med Oral Pathol Oral Radiol</secondary-title></titles><pages>183-187</pages><number>2</number><contributors><authors><author>Stathopoulos, P.</author><author>Igoumenakis, D.</author><author>Shuttleworth, J.</author><author>Frawley, T.</author><author>Ennis, C.</author><author>Battista, E.</author><author>Ameerally, P.</author></authors></contributors><edition>2016/10/13</edition><language>eng</language><added-date format="utc">1572014320</added-date><ref-type name="Journal Article">17</ref-type><rec-number>265</rec-number><last-updated-date format="utc">1572014320</last-updated-date><accession-num>27989709</accession-num><electronic-resource-num>10.1016/j.oooo.2016.10.004</electronic-resource-num><volume>123</volume></record></Cite></EndNote>30Single team4.8 yearsMaxillofacial178 SCC5.6%Cole et al.2018, UK ADDIN EN.CITE <EndNote><Cite><Author>Cole</Author><Year>2019</Year><IDText>High-risk basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance</IDText><DisplayText><style face="superscript">45</style></DisplayText><record><dates><pub-dates><date>02</date></pub-dates><year>2019</year></dates><keywords><keyword>dermatological tumours</keyword><keyword>histopathology</keyword><keyword>primary care</keyword><keyword>surgical pathology</keyword></keywords><urls><related-urls><url> basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance</title><secondary-title>BMJ Open</secondary-title></titles><pages>e023299</pages><number>11</number><contributors><authors><author>Cole, S. J.</author><author>Howes, R.</author><author>Meehan, C.</author><author>Cole, R.</author></authors></contributors><edition>2019/02/22</edition><language>eng</language><added-date format="utc">1572296520</added-date><ref-type name="Journal Article">17</ref-type><rec-number>270</rec-number><last-updated-date format="utc">1572296520</last-updated-date><accession-num>30798290</accession-num><electronic-resource-num>10.1136/bmjopen-2018-023299</electronic-resource-num><volume>8</volume></record></Cite></EndNote>45Two hospitalsUnclear time periodGeneral Practice (including special interest)200 BCC5.5%Ramdas et al.2018, NetherlandsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYW1kYXM8L0F1dGhvcj48WWVhcj4yMDE4PC9ZZWFyPjxJ
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ADDIN EN.CITE.DATA 34Regional6 yearsPlastics1 040 BCC17%Dermatology1 015 BCC7%General Practice 931 BCC30%Keith et al.2019, UK ADDIN EN.CITE <EndNote><Cite><Author>Keith</Author><Year>2019</Year><IDText>British Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists</IDText><DisplayText><style face="superscript">14</style></DisplayText><record><dates><pub-dates><date>Jul</date></pub-dates><year>2019</year></dates><urls><related-urls><url> Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists</title><secondary-title>Clin Exp Dermatol</secondary-title></titles><contributors><authors><author>Keith, D. J.</author><author>Bray, A. P.</author><author>Brain, A.</author><author>Mohd Mustapa, M. F.</author><author>Barrett, H. E.</author><author>Lane, S.</author><author>Emmerich, M.</author><author>Jakes, A.</author><author>Barrett, P. D.</author><author>de Berker, D. A. R.</author></authors></contributors><edition>2019/07/02</edition><language>eng</language><added-date format="utc">1571244524</added-date><ref-type name="Journal Article">17</ref-type><rec-number>223</rec-number><last-updated-date format="utc">1571244524</last-updated-date><accession-num>31265150</accession-num><electronic-resource-num>10.1111/ced.14034</electronic-resource-num></record></Cite></EndNote>14National 0.4 yearsDermatology2162 BCC3.0%882 SCCKiely et al.2019, UK ADDIN EN.CITE <EndNote><Cite><Author>Kiely</Author><Year>2019</Year><IDText>A retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin</IDText><DisplayText><style face="superscript">33</style></DisplayText><record><dates><pub-dates><date>Jun</date></pub-dates><year>2019</year></dates><keywords><keyword>BCC</keyword><keyword>Skin biopsy</keyword><keyword>Skin cancer</keyword><keyword>Surgical excision</keyword></keywords><urls><related-urls><url> retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin</title><secondary-title>J Plast Reconstr Aesthet Surg</secondary-title></titles><contributors><authors><author>Kiely, J. R.</author><author>Patel, A. J. K.</author></authors></contributors><edition>2019/06/27</edition><language>eng</language><added-date format="utc">1571628129</added-date><ref-type name="Journal Article">17</ref-type><rec-number>242</rec-number><last-updated-date format="utc">1571628129</last-updated-date><accession-num>31331722</accession-num><electronic-resource-num>10.1016/j.bjps.2019.06.002</electronic-resource-num></record></Cite></EndNote>33Single centre1.3 yearsPlastics694 BCC6.4%TotalsMeanMedianBCC - Dermatology 7.1%5.6%BCC - Plastics9.7%7.9%BCC - General Practice17.5%17.8%BCC - total11.1%7%SCC - Dermatology6.7%5.3%SCC - Plastics9.7%9.6%SCC - General Practice25.5%22.3%SCC - total11.8%9.0%Table SEQ Table \* ARABIC 1: Published studies of non-melanoma skin cancer since 2000 and their incomplete excision rate. Abbreviations used are NMSC = non-melanoma skin cancer, BCC = basal cell carcinoma, SCC= squamous cell carcinoma, UK = United Kingdom, USA = United States of America. * represents incomplete excision margin for all malignant lesions including melanomaAims, objectives, rationale and hypothesis To conduct a national audit of the treatment of non-melanoma skin cancer by Plastic Surgery units within the UK. This will establish the incomplete excision rate, early complications (bleeding, infection, graft/flap failure) and further management of incomplete excisions (re-excision, referral for radiotherapy) on a national scale. We hypothesize that Plastic Surgeons are treating a different subset of patients to Dermatology in the UK in terms of 1) lesion size, 2) histological subtype, 3) cosmetically sensitive areas 4) and utilising different reconstructions. We hypothesize that these will affect the incomplete excision rate causing it to be higher than that observed by UK Dermatologists.This study will allow patients to be better streamed to appropriate services and would enable more accurate information during counselling about the risks of incomplete excision or other complications.MethodsAchieving nation-wide data collection In order to recruit all Plastic Surgery units in the UK, a trainee collaborative approach will be used. The NMSC: PlastUK Collaborative is a group of trainees recruited from the Reconstructive Surgery Trials Network. The Reconstructive Surgery Trials Network is the UK clinical trials network for plastic and hand surgery. Collaborators will be asked to collect prospective data on non-melanoma skin cancer excisions during a 2.5 month period (16th March to 31st May 2020). Patients will be followed up to their first clinic appointment (up to 3 months later). Each patient’s data will be input to a secure database, hosted by REDCap system. In total, 50 Plastic Surgery units have been identified, and collaborators are expected to be recruited from >95% of these units. Units will additionally be contacted through other means such as via the British Association of Plastic Aesthetic and Reconstructive Surgeons (BAPRAS) and directly through email. Audit design This audit will compare the incomplete excision rate in UK Plastic Surgery units to the world-wide published data already discussed (BCC 7% median or 11% mean, SCC 9% median or 12% mean) and to a systematic review of this which is currently underway. To allow direct comparison of between Plastic Surgery units and Dermatology, the data collection will be based primarily on the two previous national Dermatology auditsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LZWl0aDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PElE
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ADDIN EN.CITE.DATA 13, 14 with only minor alterations. The alterations will be 1) not record risk for bleeding, risk for infection, cardiac devices or other risks, as this data was not published in the previous national Dermatology audits 2) record actual measurements of margins (rather than a range) which will allow more detailed analysis 3) additional data will be collected on the presence of lesion ulceration, the use of prophylactic antibiotics and if patients are referred on for further treatment (re-excision or radiotherapy). See table 1 and Data collection sheet v2.3 for details. Inclusion and exclusion criteria All adult patients who had a pre-operative diagnosis of non-melanoma skin cancer and undergo surgical excision will be included. Those undergoing excision via Moh’s micrographic surgery or with intra-operative frozen section will be excluded, as will incision, shave or punch biopsies. Ethics Ethics approval is not required, as the project will be classified as audit and will not involve access to sensitive or identifiable information. This was confirmed using the HRA decision tool ADDIN EN.CITE <EndNote><Cite><Author>Health Research Authority</Author><Year>2019</Year><IDText>Do I need NHS Ethics approval?</IDText><DisplayText><style face="superscript">46</style></DisplayText><record><urls><related-urls><url> I need NHS Ethics approval?</title></titles><contributors><authors><author>Health Research Authority,</author><author>Medical Research Council,</author></authors></contributors><added-date format="utc">1572970182</added-date><ref-type name="Web Page">12</ref-type><dates><year>2019</year></dates><rec-number>273</rec-number><last-updated-date format="utc">1572970244</last-updated-date></record></Cite></EndNote>46.Statistical analysis Statistical analysis will be performed comparing the novel data to the previous Dermatology audits. Group differences in continuous variables will be evaluated using the Mann-Whitney U test and Students t-test depending on data distribution. Group differences in nominal data will be analysed using Fisher’s exact test or Pearson’s chi-square test. Significance will be set at the level of p≤0.05. Statistical analysis will be carried out in SPSS version 25 (IBM, USA). Definitions A lesion will be considered incompletely excised if residual tumour is found at either the peripheral or deep margin. ‘Closely’ or ‘near to’ excised lesions will be considered as fully excised in line with previous studies and recorded as suchPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbGVpc2NoZXI8L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFy
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ADDIN EN.CITE.DATA 20. -376555479425Table 2: Data collection fields used to collect data by trainees in Plastic Surgery units in the UK. Primarily based on the previous UK national Dermatology audits. Patient demographicsDemographics Age, genderNumber of lesions being excised Pre-operative details Clinical diagnosis (BCC vs SCC)Biopsy proven?Presence of ulceration Body siteIf < 10mm from previous treatment scar (for recurrence)Primary or re-excisionOperation detailsDate of surgery Prophylactic antibiotic usePlanned clinical margin Peripheral, deep, not statedType of immediate reconstructionLeft open (or delayed reconstruction), direct closure, full-thickness skin graft, split-thickness skin graft, flap Histological detailsBCC, SCC, Bowens, Actinic Keratosis, Melanoma, Benign, OtherSubtype of BCCLargest tumour diameter (mm)Margins Peripheral margin (mm)Deep margin (mm)Involved? At which margin?ComplicationsBleeding Infection Graft/flap failure for other reason Further treatmentNo further treatment plannedClinical surveillanceListed for re-excision Referral for radiotherapy Discharged from Plastic Surgery 00Table 2: Data collection fields used to collect data by trainees in Plastic Surgery units in the UK. Primarily based on the previous UK national Dermatology audits. Patient demographicsDemographics Age, genderNumber of lesions being excised Pre-operative details Clinical diagnosis (BCC vs SCC)Biopsy proven?Presence of ulceration Body siteIf < 10mm from previous treatment scar (for recurrence)Primary or re-excisionOperation detailsDate of surgery Prophylactic antibiotic usePlanned clinical margin Peripheral, deep, not statedType of immediate reconstructionLeft open (or delayed reconstruction), direct closure, full-thickness skin graft, split-thickness skin graft, flap Histological detailsBCC, SCC, Bowens, Actinic Keratosis, Melanoma, Benign, OtherSubtype of BCCLargest tumour diameter (mm)Margins Peripheral margin (mm)Deep margin (mm)Involved? At which margin?ComplicationsBleeding Infection Graft/flap failure for other reason Further treatmentNo further treatment plannedClinical surveillanceListed for re-excision Referral for radiotherapy Discharged from Plastic Surgery In terms of complications, ‘bleeding’ will be defined as requiring return to theatre or consultation with healthcare professional due to this (includes GP/A&E who may apply direct pressure only). ‘Infection’ will be defined as requiring antibiotics, causing wound dehiscence or graft/flap failure. ‘Listed for re-excision’ will only be those patients who after discussion were formally re-listed. If patients will be monitored then they will not be included, also those who declined further surgery will not be included, but in both instances the numbers will be recorded. 4564050-32600300Data collection sheet v2.3QuestionResponsesDemographicsAgeGenderHow many suspected non-melanoma skin cancer lesions are being excised?1, 2, 3, 4, 5If 2 or more is selected, then all questions below will be repeated for the 2nd, 3rd lesions etcPre-op diagnosis (from Plastic Surgery)BCCSCCUnknown or biopsy provenIs the lesion ulcerated? Yes, No, Unknown Body siteHead and neckScalpPeriocular, temple, forehead or eyebrowCheek or chin Ear (or within 2cm)Nose (or within 1cm) or lipsNeckTrunkLimbHand or footGenitalia, perineum or perianal areaUnknown Is this area within 10mm of a previous treatment scar?Yes, No, Unknown Type of excisionDate of surgery PrimaryRe-excision Unknown Planned clinical margin from op notePeripheral (mm or unknown)Deep (mm, tissue layer or unknown)Type of immediate reconstructionLeft open (or delayed reconstruction) Direct closureSkin graftFull thickness skin graftSplit thickness skin graftUnknownFlap Unknown Did the patient receive prophylactic antibiotics? At inductionYes, No, UnknownPost-opYes, No, Unknown Histological diagnosisBCCSubtypes – can select more than one if mixedNodularInfiltrativeSuperficialMicronodularMorpheaformSclerosingAdenoidFibroepithliomatousOtherUnknownSCCActinic keratosisBowen’s DiseaseMelanomaBenign – therefore skip next 2 questions OtherLargest tumour diameterSize in mm (or unknown)Margins (from histology report)Peripheral (mm or involved)Deep margin (mm or involved) Complications Definitions above NoneBleedingInfectionGraft/flap failure for other reasonsOtherUnknown / patient not followed upFurther treatmentListed for re-excision Yes, No, UnknownReferral for radiotherapyYes, No, Unknown Discharged from Plastic Surgery?4484536-41346800References ADDIN EN.REFLIST 1. National Cancer Intelligence Network (NCIN). Non-melanoma skin cancer in England, Scotland, Northern Ireland, and Ireland. 2013.2. National Cancer Registration and Analysis Service (NCRAS). Non-melanoma skin cancer: Incidence and mortality rates in England, Scotland, and Northern Ireland. 2013.3. Vallejo-Torres L, Morris S, Kinge JM, Poirier V, Verne J. Measuring current and future cost of skin cancer in England. J Public Health (Oxf) 2014: 36: 140-8.4. Pascal RR, Hobby LW, Lattes R, Crikelair GF. Prognosis of "incompletely excised" versus "completely excised" basal cell carcinoma. Plast Reconstr Surg 1968: 41: 328-32.5. Park AJ, Strick M, Watson JD. Basal cell carcinomas: do they need to be followed up? J R Coll Surg Edinb 1994: 39: 109-11.6. Goldberg DP. Assessment and surgical treatment of basal cell skin cancer. Clin Plast Surg 1997: 24: 673-86.7. Griffiths RW. Audit of histologically incompletely excised basal cell carcinomas: recommendations for management by re-excision. Br J Plast Surg 1999: 52: 24-8.8. Telfer NR, Colver GB, Morton CA, Dermatologists BAo. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008: 159: 35-48.9. Motley R, Kersey P, Lawrence C, et al. Multiprofessional guidelines for the management of the patient with primary cutaneous squamous cell carcinoma. Br J Dermatol 2002: 146: 18-25.10. Geohas J, Roholt NS, Robinson JK. Adjuvant radiotherapy after excision of cutaneous squamous cell carcinoma. J Am Acad Dermatol 1994: 30: 633-6.11. England N. 2013/14 NHS STANDARD CONTRACT FOR CANCER: SKIN (ADULT). 2013.12. George S, Pockney P, Primrose J, et al. A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial. Health Technol Assess 2008: 12: iii-iv, ix-38.13. Keith DJ, de Berker DA, Bray AP, et al. British Association of Dermatologists' national audit on nonmelanoma skin cancer excision, 2014. Clin Exp Dermatol 2017: 42: 46-53.14. Keith DJ, Bray AP, Brain A, et al. British Association of Dermatologists (BAD) National Audit on Non-Melanoma Skin Cancer Excision 2016 in collaboration with the Royal College of Pathologists. Clin Exp Dermatol 2019.15. Malik V, Goh KS, Leong S, et al. Risk and outcome analysis of 1832 consecutively excised basal cell carcinomas in a tertiary referral plastic surgery unit. J Plast Reconstr Aesthet Surg 2010: 63: 2057-63.16. Griffiths RW, Suvarna SK, Stone J. Basal cell carcinoma histological clearance margins: an analysis of 1539 conventionally excised tumours. Wider still and deeper? J Plast Reconstr Aesthet Surg 2007: 60: 41-7.17. Barry J, Oon SF, Watson R, Barnes L. The management of basal cell carcinomas. Ir Med J 2006: 99: 179-81.18. Timmons MJ, Hessel KC, Kranidhiotis NM. Complete excision of basal cell carcinomas. Br J Plast Surg 2002: 55: 362.19. Stolle LB, Kjerkegaard UK. A single center retrospective study on 959 excisions of non-melanoma skin cancer in 2011. J Plast Reconstr Aesthet Surg 2013: 66: 1630-2.20. Fleischer AB, Feldman SR, Barlow JO, et al. The specialty of the treating physician affects the likelihood of tumor-free resection margins for basal cell carcinoma: results from a multi-institutional retrospective study. J Am Acad Dermatol 2001: 44: 224-30.21. Salmon P, Mortimer N, Rademaker M, et al. Surgical excision of skin cancer: the importance of training. Br J Dermatol 2010: 162: 117-22.22. Macbeth AE, Torley D, Casie Chetty N, et al. Audit of incomplete excision rates of basal cell carcinoma: analysis of 1972 cases from four U.K. regions. Br J Dermatol 2009: 161: 710-2.23. Twist M. Rate of incomplete excision of basal cell carcinomas by General Practitioners with Special Interest. Br J Dermatol 2009: 161: 187.24. Robinson AJ, Walsh M, Hill C. Histopathological variation of incompletely excised basal cell carcinoma's and the variation with the grade of surgeon - implications for revalidation. Eur J Surg Oncol 2015: 41: 165-8.25. Dieu T, Macleod AM. Incomplete excision of basal cell carcinomas: a retrospective audit. ANZ J Surg 2002: 72: 219-21.26. Wilson AW, Howsam G, Santhanam V, et al. Surgical management of incompletely excised basal cell carcinomas of the head and neck. Br J Oral Maxillofac Surg 2004: 42: 311-4.27. Talbot S, Hitchcock B. Incomplete primary excision of cutaneous basal and squamous cell carcinomas in the Bay of Plenty. N Z Med J 2004: 117: U848.28. Bogdanov-Berezovsky A, Cohen AD, Glesinger R, et al. Risk factors for incomplete excision of basal cell carcinomas. Acta Derm Venereol 2004: 84: 44-7.29. Cho M, Lee J, James CL, Marshman G, Huilgol SC. Scalp Basal Cell Carcinoma: Review of 2,202 Cases. Dermatol Surg 2016: 42: 834-41.30. Stathopoulos P, Igoumenakis D, Shuttleworth J, et al. Head and neck nonmelanoma cutaneous malignancy treatment in a skin cancer referral center. Oral Surg Oral Med Oral Pathol Oral Radiol 2017: 123: 183-87.31. Kumar P, Orton CI, McWilliam LJ, Watson S. Incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit. Br J Plast Surg 2000: 53: 563-6.32. Kumar P, Watson S, Brain AN, et al. Incomplete excision of basal cell carcinoma: a prospective multicentre audit. Br J Plast Surg 2002: 55: 616-22.33. Kiely JR, Patel AJK. A retrospective study of 694 Basal Cell Carcinoma excisions to quantify deep margin documentation and clearance compared to histological type and surgical margin. J Plast Reconstr Aesthet Surg 2019.34. Ramdas K, van Lee C, Beck S, et al. Differences in Rate of Complete Excision of Basal Cell Carcinoma by Dermatologists, Plastic Surgeons and General Practitioners: A Large Cross-Sectional Study. Dermatology 2018: 234: 86-91.35. Penington A. Ulceration and antihypertensive use are risk factors for infection after skin lesion excision. ANZ J Surg 2010: 80: 642-5.36. Chan SA, Wernham AGH, Stembridge N, et al. Do perioperative antibiotics reduce the risk of surgical-site infections following excision of ulcerated skin cancers? A Critically Appraised Topic. Br J Dermatol 2018: 178: 394-99.37. Hallock GG, Lutz DA. A prospective study of the accuracy of the surgeon's diagnosis and significance of positive margins in nonmelanoma skin cancers. Plast Reconstr Surg 2001: 107: 942-7.38. Hussain M, Earley MJ. The incidence of incomplete excision in surgically treated basal cell carcinoma: a retrospective clinical audit. Ir Med J 2003: 96: 18-20.39. Deo SV, Hazarika S, Shukla NK, et al. Surgical management of skin cancers: experience from a regional cancer centre in North India. Indian J Cancer 2005: 42: 145-50.40. Dhepnorrarat RC, Lee MA, Mountain JA. Incompletely excised skin cancer rates: a prospective study of 31,731 skin cancer excisions by the Western Australian Society of Plastic Surgeons. J Plast Reconstr Aesthet Surg 2009: 62: 1281-5.41. Haque Hussain SS, Shams N, Garioch JJ. Managing squamous cell carcinomas: audit on the mode of referral and adequacy of surgical excision. Br J Dermatol 2009: 160: 224-5.42. Seretis K, Thomaidis V, Karpouzis A, Tamiolakis D, Tsamis I. Epidemiology of surgical treatment of nonmelanoma skin cancer of the head and neck in Greece. Dermatol Surg 2010: 36: 15-22.43. Delaney EK, Duckworth L, Thompson WD, Lee AJ, Murchie P. Excising squamous cell carcinomas: comparing the performance of GPs, hospital skin specialists and other hospital specialists. Fam Pract 2012: 29: 541-6.44. Luz FB, Ferron C, Cardoso GP. Analysis of effectiveness of a surgical treatment algorithm for basal cell carcinoma. An Bras Dermatol 2016: 91: 726-31.45. Cole SJ, Howes R, Meehan C, Cole R. High-risk basal cell carcinoma excision in primary care: a retrospective observational study of compliance with NICE guidance. BMJ Open 2019: 8: e023299.46. Health Research Authority, Medical Research Council. Do I need NHS Ethics approval? 2019. ................
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