CANCER CARE
Dr Saul Halpern, chairman of the British Teledermatology Society, discusses the controversial use of teledermatology in diagnosing cancer.
A
debate has been raging over the ac- curacy and effectiveness of diagnos-
ing skin cancer via investigation of an im- age of the affected area of skin.
Opponents argue that it will never be as good as seeing a patient face-to-face, yet others suggest it can cut waiting times, es- pecially for people who can be discharged immediately. The practice is already wide- ly used and accepted in countries such as New Zealand and Spain.
Dr Saul Halpern, chairman of the British Teledermatology Society, and a consultant the Department of Dermatology at Medway NHS Trust in Kent, spoke to NHE about the advantages of managing diagnosis quickly, without the need for patients to travel fur- ther to see a specialist dermatologist.
He said: “We use it as part of our service to triage skin cancers, partly to manage demands and targets. There is such a huge fluctuation in rates of referrals; we cover an area of 1 million people, and we may get anything from 30 to 100 potential cancer referrals a week.
“We can use teledermatology flexibly; it enables you to triage cases out.”
Elimination
Eliminating a large number of cases can ensure that people with possibly harmful lesions are prioritised onto relevant sur- gery lists more quickly.
Dr Halpern continued: “About 90% are not anything we need to worry about or deal with urgently, so at least half of them can actually be discharged straight back with- out even seeing the patients, if we’ve got good enough images.
“If you have large distances and you can get good quality images from nearer to the patient, they don’t necessarily have to trav- el to the main hospital to be seen. A GP can refer on for an expert opinion, to someone who is able to differentiate between lesions that are harmless and those which could be malignant. We don’t actually need to see the patient in the flesh; you can look at a blown-up detailed image on a computer screen. Nine times out of ten you can make
He said: “It is controversial; it’s not neces- sarily widely accepted. I think it is the way forward and it has gradually gained accep- tance, but it is very much dependent on getting the right system working and the right quality of images. If the images aren’t good enough then of course it’s useless: you’ve still got to see the patient.
“It does enable you to rule out things that are definitely harmless and prioritise things that might be a higher grade malig- nancy to get them dealt with.”
The right tool for the job
Training for staff to take high-quality im- ages depends on the system being used, Dr Halpern said. Commercial companies will train staff for this purpose, while others just “learn on the job”.
He continued: “If the images aren’t good, we can feed that back and get that ad-
a good educated guess whether it’s benign or malignant.
“If it is malignant, you can potentially ar- range for them to see a specialist or put them straight onto a surgery list. If it’s a low-grade malignancy, that can receive a lower priority, and if it’s something com- pletely harmless you can feed that informa- tion back to the patient and the GP and not see them at all.”
Hot topic
With publications and opinion divided on the subject, Dr Halpern suggests that a good system of quality images can bring benefits to the system of skin cancer diagnosis.
dressed. Most cameras these days are pret- ty easy to use.”
Cameras are still the technology of choice, and while smartphones are starting to be used for other dermatology issues, the im- age quality remains insufficient for use with skin cancer.
Dr Halpern said: “You need special micro- scopic attachments, dermatoscopes, which you can use with cameras. That gives you a special microscopy image which gives a lot more information than simply looking by eye.
“Phones have been used to take images of rashes, but not for skin cancer. I don’t think it’s quite good enough for that yet.”
Image of the future
Increasing the use of this form of diagno- sis is all to do with raising awareness, Dr Halpern suggests.
He said: “I think it is an educational thing. It is still quite a hot topic; it does bring up a lot of debate because people say it’s never as good as seeing the patient face-to-face.
“It probably isn’t and there are a number of reasons for that; you can’t actually feel it [the lesion], you can’t look around it at dif- ferent angles and with different lights and more importantly you can’t look at the rest of the patient.
“Sometimes if a patient is referred with one particular lesion, it’s not that uncom- mon that when you actually see them, that lesion is fine but they’ve got another one somewhere else that might not be, and you wouldn’t have picked that up if you’d just had one image.”
He concluded: “As a basic triage it is po- tentially a cost effec- tive way of dealing with numbers, but it is not a replacement for standard care and seeing the specialist face-to-face.”
Visit
www.teledermatology.co.uk Dr Saul Halpern
FOR MORE INFORMATION national health executive Nov/Dec 11 | 71
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