Information for Doctors

Skin Integrity offers several services that can assist GPs in the management of their patients.  These services involve aspects of skin cancer surveillance, diagnosis, surgical and non-surgical management.  GPs are welcome to refer patients for an opinion; management of a specific problem or ongoing management of high risk patients.  Referral forms are available to assist with this process and Dr Wassall will correspond with the referring GP.  In addition, Skin Integrity also offers sessional use of its theatre facilities for GPs that wish to manage their skin cancer patients personally (see below for more details).

 

Total Body Photography (TBP)

TBP has become an invaluable tool for assisting early melanoma detection in high risk patients.  Studies have also found TBP useful for assisting detection of non-melanoma skin cancer in at risk patients over the age of 50. TBP is a surveillance tool designed to provide baseline images that the patient can use to allow them to perform comparison checks at home.  It is also a very useful method of improving sensitivity during full skin examinations performed by doctors.

Photographs are performed in a dedicated studio environment by our Registered Nurse.  Around 30 high resolution photos are taken to document over 90% of the cutaneous surface.  Images are kept on Skin Integrity's server and a copy is provided to the patient on USB.  A full skin examination is not performed and the patient is returned to their usual GP for ongoing care. An SMS message is sent to the patient approximately every 3 months to remind them to check their skin with the aid of the photographs.  Any change or new lesion noted by the patient necessitates follow up by the patients GP.

For more information on Total Body Photography click here.

 

Management of Proven or Suspected Skin Cancer

Consultations for specific management includes the following:

Opinion and/or follow up of suspicious lesion.

• Dr Wassall is happy to provide an opinion on pigmented skin lesions.  Generally a definitive diagnosis can be provided and, if necessary, high resolution dermoscopic photographs of pigmented lesions can be performed to allow short term digital monitoring.  Similarly, opinions can be provided on suspected non-melanoma skin cancer with regards to diagnosis or management options.  If requested, the patient will be returned to the referring GP for management or the management can be performed at Skin Integrity.

Surgical Management.

• Dr Wassall has extensive experience and post graduate training in the surgical management of melanoma and non-melanoma skin cancer.  Attention is paid to providing appropriate margins and he uses dissolvable internal sutures for all surgical repairs in order to optimise cosmetic outcomes.  All procedures are performed in a dedicated theatre with nursing assistance.  Dr Wassall performs elliptical excisions, wedge excisions of ear lesions, a variety of flap repairs and halo grafts (a type of split thickness skin graft) on lower limbs.  He does not perform the following as he believes these procedures are best performed by a Plastic Surgeon in a hospital environment.
  • Full thickness skin grafts
  • Split thickness skin grafts apart from halo grafts on lower limbs
  • Flap repairs on the central face (nose, eyelids and lips)
  • Flap repairs of the lower limbs
  • Full thickness lip excisions
• Skin Integrity is happy to accept referrals for surgical treatment of skin cancers or lesions that fit within the above criteria.  The aim is to be able to offer patients a more cost effective alternative than referral to a Plastic Surgeon for lesions that may beyond the scope of expertise or comfort level of the patients GP.

 

Photodynamic Therapy (PDT)

PDT is a non-surgical treatment option for field treatment of actinic keratoses as well as management of certain non-melanoma skin cancers (particularly superficial BCCs and Bowen's Disease).  PDT involves incubation of the area or lesion with a photosensitiser followed by activation of the photosensitiser with a light source (specific wavelengths from an LED light source are used).

At present, Skin Integrity is using compunded 5-aminolevulinic acid (5-ALA) as the photosensitiser.  There have been concerns raised about the stability of compounded 5-ALA.  A more stable photosensitiser, metvix, is available in Australia but it is cost prohibitve, particularly when used as a field treatment for actinic keratoses.  From early 2012, Skin Integrity will also be offering metvix as a photosensitiser.  Metvix is subsidised for DVA patients and, in Dr Wassall's opinion, will be a superior photosensitiser than compounded 5-ALA particularly for treatment of nodular BCCs and treatment of supericial BCCs and Bowen's Disease in areas at high risk of recurrence such as the nose and ears.

Actinic Keratoses.

PDT is an excellent treatment for actinic keratoses. Current research suggest that actinic keratoses are dynamic with some lesions regressing, some remaining stable and a small percentage progessing to invasive SCC.  For patients with signs of extensive solar damage and actinic keratoses, particulary on the face, field treatment of the entire area is considered superior to treatment of individual lesions. A single PDT treatment has similar efficacy to treatment with efudix or aldara but with significantly less social downtime and superior cosmetic outcomes.  Skin Integrity will continue to use  compounded 5-ALA for this procedure due to cost considerations.  However, subsidised field treatment for actinic keratoses with metvix is available for DVA patients.

Superficial BCC and Bowen's Disease.

PDT is considered the treatment of choice for these lesions in certain circumstances such as large lesions in difficult to heal areas such as lower limbs.  Generally two treatments are required to achieve a cure rate of around 85 to 90%.  Skin Integrity currently uses compounded 5-ALA for this treatment but from early 2012 will also offer metvix.  Metvix treatment will be considerably more expensive.  However, DVA patients qualify for subsidised metvix PDT for biopsy proven superficial BCCs and Bowen's Disease.

Nodular BCC.

Metvix PDT is a suitable treatment for nodular BCCs under certain circumstances.  It gives excellent cosmetic outcomes with good cure rates.  It is only suitable for lesions less than 1mm in depth (due to penetration limnitations of the light source) and is not suitable for aggressive histological subtypes of BCC such as morphoeic or micronodular BCCs.

Generally two treatments are required one to two weeks apart.  Compounded 5-ALA is not used at Skin Integrity for nodular BCCs.

 

Theatre Sessions

Skin Integrity has available a dedicated operating theatre with quality surgical instruments and nursing support.  GPs that wish to perform procedures within this facility can book the theatre on a sessional basis.  Sessions are generally of 3.5 hours duration.  Apart from offering a dedicated environment to perform these procedures, doctors also have the opportunity to potentially significantly increase their income from performing minor surgery.

The arrangements for this service are as follows:

• Sessions are booked through Skin Integrity on a first come first served basis.  It is quite acceptable to book sessions well in advance to secure them GPs Practice is responsible for booking patients.
• Theatre list emailed or faxed to Skin Integrity at least 24 hours prior to session.  Skin Integrity will attempt to contact patient to confirm appointment.
• Skin Integrity will provide instruments and surgical materials.  Please contact Dr Wassall for a list of instruments and materials available, particularly if you have specific instrument requirements.
• Nurse is available to administer local anaesthetic, assist with procedure and apply post-op dressing.
• Patient returns to GPs usual surgery for suture removal and follow up.
• Skin Integrity will bill patient a facility fee for use of theatre and consumables.  This is generally $150 plus GST for private patients and $100 plus GST for concession card holders.  Multiple procedures performed within the same visit, complex and time consuming procedures attract a higher facility fee (up to $250).  It is the responsibility of the GP or their practice to explain the facility fee arrangement to the patient.
•  Skin Integrity requires a minimum of $400 in facility fees per session to make this service viable.  If Skin Integrity fails to collect $400 in facility fees for the session, the GP will be required to contribute the balance.  The doctor bills the patient separately for the procedure and keeps 100% of this fee.  Skin Integrity is able to organise bulk billing of patients for the procedure with deposits directly into GPs bank account.  If the GP elects to bill the patient privately, their practice will need to take responsibility for the account. 
• Consent forms are available which outline risks as well as explaining the billing procedure.
• Please contact Dr Wassall to discuss this arrangement in more detail

Employment Opportunities

Skin Integrity is a privately billing, premium facility which focuses on delivering high quality Skin Cancer diagnosis and treatment.  Fees are set accordingly to allow us to deliver this level of service.  We are paperless and have Registered Nurses to assist in dermoscopic assessment and photography, total body photography, performing punch biopsies and basic suturing, administering local anaesthetic, theatre set up and assisting, dressings and suture removal.

At present, Dr Wassall is running this clinic independently. His vision is to expand this model of care with similarly minded doctors.  Initially this will occur at our current location in Terrigal but ultimately he wishes to expand and open a purpose built facility.  If you have recognised post graduate experience and training in Skin Cancer medicine and dermoscopy, a commitment to excellence and are interested in joining the team, please contact Dr Wassall on 4384 6191 or email your CV to doctor@skinintegrity.com.au.