P155 An audit to evaluate the diagnostic and surgical pathway of basal cell carcinomas at a district general hospital

Abstract This audit evaluated the diagnostic and surgical treatment pathway of basal cell carcinomas (BCCs) at a district general hospital and benchmarked findings against the British Association of Dermatologists (BAD) national nonmelanoma skin cancer excision audit 2016. Key areas included patient demographics, referral pathways, lesion characteristics, procedure types, excision margins, clinical–histological concordance, histology reporting timeliness and patient outcomes. The audit also assessed the potential role of Mohs surgery, currently unavailable onsite, in improving treatment pathways. In total, 200 patients diagnosed with BCCs via histology between September and December 2023 had their patient records, clinic letters and histology reports retrospectively reviewed. The mean age of the patients was 75 years (range 34–102); 54.5% were male. In total, 36% were referred via the 2-week-wait pathway, with 45% of referral types undocumented. Clinical–histological concordance was 91% (85% BCC as standalone diagnosis; 6% BCC vs. differential). Mixed BCC was the most common subtype. Common sites included the nasal ala (10.5%), chest (6.5%) and nose (5.5%). The mean tumour diameter ranged from 6 to 10 mm. Direct excision achieved complete excision with good margins in 83%. Marginal outcomes included 6% with involved margins, 6% with clearance < 1 mm, and 3% with clearance < 0.5 mm. Only 9.5% of cases were considered for Mohs surgery, despite 48% being anatomically suitable. The mean time from histology report to clinic outcome communication was 8 days, with 25% reported the same day and 20% the next day. Only 22% of histology reports were available within 10 days of excision (mean 33 days). In total, 54% of patients were discharged to primary care, and 21% required follow-up. In conclusion, this audit highlighted strengths and gaps in the BCC management pathway. (i) Clinical–histological concordance (91%) was slightly below the national average of 95%. (ii) Complete excision margins (83%) were below the national average (∼98%). (iii) Histology reporting timeliness was suboptimal: only 22% met the Royal College of Pathologists’ 10-day target (mean 33 days). Communication from clinician to patient after the report was prompt (mean 8 days). To meet the faster diagnosis standard (28-day target from referral to outcome communication), improvements are needed in diagnostic and treatment pathways. Identified gaps include inadequate referral documentation, underutilization of Mohs surgery, and inconsistent alignment with National Institute for Health and Care Excellence general practitioner referral guidelines (routine rather than 2-week-wait referrals for low-risk BCCs). Recommendations for practice are (i) to standardize referral pathway documentation through templates; (ii) to increase general practitioners’ awareness of routine referral guidelines for BCCs; (iii) to introduce a dermatology surgical logbook to monitor excision margins, support clinician reflection and facilitate reauditing; and (iv) to enhance local access to Mohs surgery to optimize treatment outcomes.