Integrated care pathways and the hub-and-spoke model for the management of non-melanoma skin cancer: A proposal of the Italian Association of Hospital Dermatologists (ADOI)

Abstract

The term non-melanoma skin cancer (NMSC) refers to skin cancer different from melanoma, and it is usually restricted to basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and their pre-cancerous lesions, e.g., actinic keratosis. These conditions represent the most frequent tumors in Caucasians and are characterized by an increasing incidence worldwide and a high socio-economic impact. The term Integrated Care Pathway (ICP) refers to "a complex intervention for the mutual decision making and organization of care processes for a well-defined group of patients during a well-defined period". The purpose of this paper is to present a proposal from the Italian Association of Hospital Dermatologists (ADOI) for an ICP organization of care of NMSC, considering the hub-and-spoke model in the different geographical areas. This proposal is based on the most recent literature and on documents from the Italian Association of Medical Oncology (AIOM), the European consensus-based interdisciplinary guidelines from the European Association of Dermato- Oncology (EADO), and the National Comprehensive Cancer Network (NCCN). We initially discuss the NMSC outpatient clinic, the role of the multidisciplinary working groups, and the hub-and-spoke model regarding this topic. Then, we define the ICP processes specific for BCC and SCC. The ICP for NMSC is an innovative strategy to guarantee the highest possible quality of health care while the hub-andspoke model is crucial for the organization of different health care structures. Considering the importance on this topic, it is essential to create a valid ICP together with an efficient organization within the different geographical areas.

Keywords: Actinic keratosis; Basal cell carcinoma; Integrated care pathway; Nonmelanoma skin cancer; Squamous cell carcinoma; hub and spoke model.

Figure 1.

The hub-and-spoke model. The hub-and-spoke organization design is a model characterized by service delivery assets into a network involving an anchor establishment (hub) offering a full array of services, complemented by secondary establishments (spokes) offering more limited service arrays, routing patients needing more intensive services to the hub for treatment.

Figure 2.

The integrated care pathway for non-melanoma skin cancers between different institutional centres. Local dermatology outpatient clinic should treat patients affected by low risk BCC or SCC, while, general hospital with a Dermatology Unit could manage intermediate and high-risk BCC or high and very high risk SCC. More complicated cases (i.e., locally advanced or metastatic BCC or SCC, high risk BCC, or very high-risk SCC) should be managed by tertiary node with skin cancer centres and oncologic services organised in multidisciplinary working group (MWG). GP: general practitioner; PDT: photodynamic therapy; MWG: Multidisciplinary working group; RT: radiotherapy; ECT: electrochemotherapy.

Figure 3.

Multidisciplinary working group. The multidisciplinary working group (MWG), integrating their specific skills, include professional figures such as dermatologist, medical oncologist, general surgeon, plastic surgeon, radiation oncologist, radiologist, anatomopathologist, and epidemiologist.

Figure 4.

Main therapeutic indications for locally advanced and metastatic cutaneous SCC as indicated in the “European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2” in 2020. SCC, cutaneous squamous cell carcinoma; RT, radiotherapy; EGFRi, epidermal growth factor receptor inhibitors.