The Royal Flying Doctor Service primary care skin cancer clinic: a pilot program for remote Australia

Introduction: The geography and logistics of living in remote Australia provide unique challenges in providing dedicated primary healthcare services to tackle the rising incidence of skin cancer. The aim of this study was to ascertain whether the Royal Flying Doctor Service (RFDS) skin cancer clinic could improve skin cancer health outcomes for the target population while providing care at a level consistent with that documented for metropolitan skin cancer clinics. Methods: This retrospective longitudinal report compared historical controls with a dedicated fly-in/fly-out primary care skin cancer outreach clinic provided by the RFDS. The clinic was run concurrently with the regular primary care medical service; the entire focus of this additional service was on skin cancer diagnosis and management. This model was used to minimise the additional costs of providing the service. Results: During the study period a total of 316 people were seen at this skin cancer clinic (29% of the total non-Indigenous population) with 39% of those aged over 50 years seen. There was an average of 1.1 consultations per person (343 consultations in total), with a procedure performed in approximately one-third of consultations. The demographic most likely to have a lesion removed were over 50 year-old males (p<0.0001). The rate of skin cancer detection was 15/1000 adults/year. The number of lesions removed per year increased from 37 to 42 after the intervention, with no statistically significant change in the percentage of excised lesions that were malignant (44%). For over 50 year-old males there was a statistically significant increase in the proportion of excised lesions that were melanomas (chi(2) = 6.015; p = 0.013). This corresponded to a four-fold rise in melanoma detection from 0.2/1000 people/year pre-intervention to 2/1000 people/year post-intervention. A comparison of the skin clinic's effectiveness with documented results from other Australian non-specialist skin cancer services demonstrated a low number needed to treat for melanoma which is consistent with high diagnostic accuracy. This is also supported by a relatively high consultation to biopsy ratio. The biopsy treatment ratio and percentage of lesions that were malignant were similar to those seen in other Australian settings. Conclusion: The RFDS skin cancer clinic outcomes were not dissimilar to those seen in metropolitan skin cancer clinics. The small population and consequently low statistical power mitigated against certainty in concluding that clinical outcomes were enhanced. Further studies would assist in the future development of models for skin cancer clinics in remote areas.