Making a difference to skin cancer care: considering different types of evidence

The Nottingham Centre for Evidence Based Healthcare (CEBHC), at the University of Nottingham, is a JBI Centre of Excellence whose members are experienced academic researchers, information scientists and clinical practitioners engaged in evidence synthesis. The Nottingham CEBHC’s motto is ‘…in collaboration, we publish evidence reviews using a variety of methodologies with the aim of improving healthcare practices for the benefit of patients and practitioners all over the world’. This case study describes how academics from the Nottingham CEBHC utilised a range of evidence synthesis methodologies to make a difference to skin cancer care.

Skin cancer is the most common type of cancer in human beings, and its incidence has been increasing in the UK and worldwide over the past two decades. Skin cancer comprises mainly melanoma and non-melanoma skin cancer. Whilst melanoma is much less common than non-melanoma (with an estimated two to three million new cases of non-melanoma skin cancer each year compared to approximately 132,000 new cases of melanoma1), melanoma skin cancer is the most dangerous type, being responsible for nearly 60,000 deaths annually. 

The two main types of non-melanoma skin cancer are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Collectively, BCCs and SCCs are called keratinocyte carcinoma. If left untreated, or if inadequately treated, BCCs can cause extensive destruction to tissue, particularly on the face. BCC rarely spread, but in rare cases can infiltrate the bone and deeper structures such as the brain and cause death. In contrast, SCCs are generally more likely to grow and spread to other parts of the body.

Between 2003 and 2007, colleagues from the Nottingham CEBHC undertook a series of Cochrane systematic reviews to look at treatment options for BCC.^2-5 The findings from these reviews informed the British Association of Dermatologists guidelines,⁶ the National Institute for Health and Clinical Excellence (NICE) guidelines⁷ and the design of a randomised controlled trial (RCT) of a topical treatment called Imiquimod compared to the standard treatment of surgical excision.⁸ This five-year trial informed the clinical practice of treating low-risk BCCs.⁹

In 2010, the Nottingham CEBHC published a Cochrane systematic review summarising evidence from RCTs on interventions for cutaneous SCC (cSCC).¹⁰ Unfortunately, only one small trial comprising 65 people met the inclusion criteria, but the treatment under investigation was not commonly used in clinical practice. Therefore, the systematic review concluded that there was little evidence from RCTs regarding the effectiveness of interventions for cSCCs.   

In response to the lack of evidence from RCTs, the Nottingham CEBHC conducted a systematic review of observational case series studies to assess the effects of common treatments used in everyday practice for cSCC.¹¹ The systematic review included 118 observational studies, and the findings from the review were used to inform two clinical guidelines (the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline on the management of cSCC¹² and the NHS evidence update on improving outcomes for people with skin tumours including melanoma9). However, none of the studies included patient-reported outcome measures, such as quality of life, hence the effects of the treatments from the patients’ perspective could not be inferred. 

To address this gap, in 2016 a team from the Nottingham CEBHC published a qualitative systematic review, using JBI’s pragmatic meta-aggregative approach to explore the needs and experiences of patients diagnosed with any type of skin cancer.¹³ This review highlighted how the time of diagnosis was a period of shock and distress for patients, especially for those who believed their symptoms to be mild and nothing to worry about. The review showed there was a need for more information and support for patients at this time. Other findings were that the skin cancer diagnosis had a range of potentially long-term physical, psychological, social and financial impacts, which needed to be understood and addressed. 

The post-treatment follow-up period was characterised by a state of liminality, with many patients continuing to worry about possible recurrence and needing education and support. Finally, the review found that patients were comforted by healthcare providers who were knowledgeable and reassuring, and that this was enhanced where services were structured in such a way as to optimise ongoing communication with clear follow-up pathways. The review identified a need for further qualitative research to be undertaken on this topic and several primary studies have since been published. In addition, the review was highlighted in a leading medical dermatology journal as being an exemplar of how qualitative research can contribute to evidence-based practice.¹⁴ 

The CEBHC is proud that its expertise in conducting evidence syntheses using a wide range of methodologies (for example, prevalence and incidence, aetiology and risk factors, intervention, and qualitative) has enabled its research to be used to inform clinical guidelines to improve healthcare practices. Additionally, due to the methodological complexities of the review, the authors of the systematic review were co-opted as members of the guideline development group to share their expertise with the wider group. 

Authors
Leonardi-Bee J¹ 
Bath-Hextall F^1,2
Evans C¹

1. Nottingham Centre for Evidence Based Healthcare, Faculty of Medicine and Health Sciences, University of Nottingham, Medical School, Queen’s Medical Centre, Nottingham, NG7 2UH

2. Emeritus Professor of Evidence Based Healthcare