GPAtlas🧭 When to suspect
Skin cancer is the most common malignancy in the UK, and the great majority is both preventable and, when caught early, curable. Three tumours account for almost all cases:
• Basal cell carcinoma (BCC) is by far the commonest – locally invasive but very rarely metastatic.
• Cutaneous squamous cell carcinoma (SCC) is the second commonest and carries a small but real risk of spread.
• Malignant melanoma is less common but is responsible for most skin-cancer deaths, because its prognosis is dictated by how deep it has grown (Breslow thickness) by the time it is removed.
The primary-care task is recognition and timely referral, not definitive diagnosis – that is histological. Two skills matter most:
• Spotting the pattern of each tumour.
• Choosing the correct referral route:
• Melanoma and SCC travel on the suspected cancer pathway (previously the two-week wait).
• BCC is usually a routine referral.
The unifying trigger is a new or changing lesion, classically on sun-exposed skin. For melanoma, the ABCDE features are a useful prompt:
• Asymmetry
• Border irregularity
• Colour variation
• Diameter (often > 6 mm)
• Evolving or elevated
Melanoma also arises on the trunk, soles, palms and nail beds, so a high index of suspicion is needed for the lesion that simply looks different from all the others.
| Type | Typical primary-care appearance | Default referral route |
|---|---|---|
| Melanoma | • New or changing pigmented lesion • ABCDE features • Weighted 7-point checklist ≥ 3 • The "ugly duckling" |
Suspected cancer pathway |
| SCC | • Firm, enlarging, keratotic or ulcerated nodule, often tender • A non-healing lesion • May arise within actinic keratosis |
Suspected cancer pathway |
| BCC | • Pearly or waxy nodule with telangiectasia • A rolled-edge "rodent ulcer" • Or a flat scaly patch that heals and re-opens |
Routine (suspected cancer pathway only if site/size threatens significant harm) |
|
🧠 Clinical pearl • The most useful sign is often the ugly duckling – the lesion that simply looks different from the patient's other moles. • The ugly duckling sign can outperform any single ABCDE feature. • Beware too the nodular and amelanotic melanoma: a new, firm, rapidly growing nodule that is symmetrical and evenly coloured (even pink or skin-coloured) can still be melanoma. • Growth and change trump a reassuring appearance. |
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