DS20 Impact of delays in surgical management of skin cancer

Abstract The James Lind Alliance (JLA) Priority Setting Partnership (PSP) identified the effects of delays in skin cancer surgery on patient outcomes as a top 10 research priority. Skin cancer is the most prevalent malignancy in England, with an estimated 215 000 cases diagnosed annually. NHS England has established targets for timings of diagnosis and treatment, recommending achieving diagnosis within 28 days (Faster Diagnosis Pathway) and treatment initiation within 31 days of the decision to treat (31-day Treatment Standard). This investigation evaluates the consequences of surgical delays on patient outcomes. We conducted a retrospective review of patients referred to our dermatology service between January 2023 and December 2024 who breached the 28-day Faster Diagnosis Pathway. Data were obtained from the Skin Cancer Data Support Team. Exclusion criteria included patients treated at other Trust sites, and those with benign and basal cell carcinoma diagnoses on histopathology. The final cohort consisted of 92 patients. The mean patient age was 76.6 years, with 60 male patients (65%) and 32 female (35%). The mean time from referral to histopathological diagnosis was 51.4 days, exceeding the 28-day standard. However, the mean interval from multidisciplinary team decision to surgery was 30.2 days, meeting the 31-day rule. Squamous cell carcinoma was the most prevalent diagnosis (67 cases, 73%), followed by malignant melanoma (22 cases, 24%). The most common cause of diagnostic delays was the need for a biopsy prior to treatment (45 cases, 49%). Other reasons included nondiagnostic teledermatology reviews (13 cases, 14%), patient-related factors (seven cases, 8%), lesion progression necessitating specialist referral (seven cases, 8%) and the need for a second biopsy (two cases, 2%). Delays influenced management in some cases, with 4% of patients requiring more extensive surgery due to lesion progression (e.g. increase in size). Additionally, 40% were referred to other specialties, increasing waiting times. Further surgical intervention following initial surgery was needed in 23% of cases, while 14% required adjuvant radiotherapy. Perineural invasion was present in three patients (3%), lymphovascular invasion in two (2%) and local or distant metastases in 10 (11%). Histological grade changes between biopsy and excision were observed in three cases. Surgical delays may negatively impact skin cancer outcomes, leading to more complex procedures and additional treatments. In our cohort, the primary cause was prolonged wait times for diagnostic biopsy, exacerbated by teledermatology increasing biopsy demand and minor operation wait times. Our investigation could not demonstrate the extent to which these findings were directly attributable to surgical delays. Further studies comparing delayed and timely treatment are needed to quantify their impact on prognosis and treatment burden.