Suspicion & referral
From a primary-care suspicion to an accepted specialist referral: NICE NG12 thresholds, the weighted 7-point checklist for pigmented lesions, teledermatology, Cancer Waiting Times standards, and the UK skin-of-colour diagnostic equity gap.
Who triggers a 2-week-wait referral?
NICE NG12 (Suspected cancer: recognition and referral) is the canonical UK reference. Two distinct skin pathways exist within NG12 — pigmented-lesion (suspected melanoma) and non-pigmented (suspected cSCC). BCC is referred on the routine skin-cancer pathway because of its indolent natural history.
Suspected melanoma
Refer urgently (2-week-wait) any patient with a pigmented or non-pigmented lesion suggestive of melanoma. NG12 uses the Williams (NICE-adapted) weighted 7-point checklist to operationalise primary-care suspicion:
| Major (2 points each) | Minor (1 point each) |
|---|---|
| Change in size | Largest diameter ≥ 7 mm |
| Irregular shape (asymmetry) | Inflammation |
| Irregular colour | Oozing |
| — | Change in sensation |
A total score of 3 or more triggers a 2WW referral. A score below 3 with strong clinical suspicion can still be referred — clinical judgement overrides the score. Use the on-site 2-week-wait checker for explicit scoring.
Suspected cSCC
NG12 recommends 2WW referral for non-healing keratinising or crusted lesions > 1 cm with significant induration, particularly when on high-risk anatomy (lip vermilion, ear, peri-orbital region) and in older or immunocompromised patients. Recurrent or rapidly growing keratinising lesions on chronically sun-damaged skin should also trigger the pathway.
Suspected BCC
Routine (non-2WW) skin-cancer pathway is appropriate for most BCCs given the slow natural history. Urgent referral is reserved for advanced, recurrent or anatomically difficult lesions (orbital, naso-jugal groove, deep H-zone) where delay would compromise reconstruction.
Teledermatology and community pathways
The UK has rapidly adopted teledermatology as a first-line triage tool. Two models are widely deployed:
- Store-and-forward — GP captures standardised macro + dermoscopic images of the lesion and a contextual photograph of the surrounding skin field, plus a short structured proforma; transmitted to a consultant-led triage service. The consultant returns a triage decision (urgent face-to-face, routine, return to GP with management advice, or community minor surgery) usually within 2 weeks of receipt.
- Direct-to-clinic — used by some trusts for high-suspicion lesions, bypassing the triage stage and booking the patient directly into a 2WW pigmented-lesion or cSCC clinic slot.
Image quality matters: NHS England guidance specifies a polarised dermoscope, clear focus, perpendicular framing, and a reference scale where feasible. Poor-quality images degrade triage accuracy; if image quality is inadequate, the patient should be redirected for face-to-face assessment rather than triaged in error.
What to include in the referral
A high-quality 2WW skin referral letter typically includes:
- Lesion duration and rate of change — onset, growth interval, recent acceleration
- Symptoms — bleeding, ulceration, pain, paraesthesia, pruritus
- Personal cancer history — previous melanoma / NMSC, prior lesions excised, prior pre-malignant treatment
- Family history — particularly melanoma in first-degree relatives; pancreatic cancer (CDKN2A); uveal melanoma, mesothelioma or RCC (BAP1)
- Immunosuppression status — solid-organ transplant, haematological malignancy, biologic immunosuppression
- Fitzpatrick skin type — relevant for both background risk and visual interpretation
- Standardised photography — macro and dermoscopic where teledermatology pathway used
- 7-point checklist score for pigmented lesions
- Patient communication needs — interpreter, accessibility
Cancer Waiting Times standards
NHS England operates several standards downstream of a 2WW referral:
- Faster Diagnosis Standard (FDS) — 28 days from 2WW referral to a definitive diagnosis being communicated to the patient (or to cancer being ruled out). The replacement for the older 2-week-wait first-appointment target.
- 62-day standard — 62 days from the 2WW referral to first definitive treatment.
- 31-day standard — 31 days from the decision-to-treat to first treatment for that patient.
Performance is reported monthly by trust and is closely watched. Skin cancer is the highest-volume 2WW tumour group in the NHS by referral count, so workflow design in dermatology / plastic surgery / MDT services has substantial knock-on effects.
Equity considerations
Skin cancer mortality is disproportionate in Fitzpatrick IV–VI populations because of:
- Acral lentiginous melanoma on plantar, palmar, subungual and mucosal sites — easily mistaken for traumatic pigmentation, tinea nigra, or benign acral naevi. Threshold for biopsy on acral / digital lesions should be low.
- Marjolin's ulcer in chronic burn scars, hidradenitis suppurativa fistulae and discoid lupus scarring alopecia — disproportionate risk in skin of colour.
- Visual diagnostic patterns — many UK training materials underrepresent Fitzpatrick IV–VI; a "non-textbook" appearance shouldn't reassure.
- Healthcare access — delayed presentation is more common in patients with English language barriers, those with limited registered-GP access, and refugee / asylum-seeker populations. Trust-level outreach matters.
What happens after the referral lands?
The receiving service (usually a consultant-led pigmented-lesion clinic or skin-cancer 2WW dermatology / plastic surgery clinic) is responsible for arranging the next step — typically a face-to-face review with dermoscopy and clinical photography, followed by biopsy or excision as appropriate (see Step 2 — Diagnosis & biopsy). Some trusts use the "see-and-treat" model: assessment and lesion excision under local anaesthetic in the same clinic appointment, with histology reviewed at the next MDT.