Accountability

Dr Paul Alsop believes that accountability in skin cancer care requires transparency around outcomes, not just clinical intent.
To support this, histopathology results from skin cancer diagnosis and surgery are periodically reviewed and summarised as part of an outcomes audit.

A person working on a laptop at a desk, with a coffee cup, notebook, and pen nearby, and a clipboard displaying charts and graphs.

The information below presents a 12-month audit of independently reported histopathology results across 5 clinics. In contrast to registry-based audits that rely on clinician self-reporting, this review is generated directly from pathology data, reducing reporting bias and providing an objective measure of outcomes.

Source: Pathlab

For Patients

2026 Audit

A doctor holding a clipboard and explaining health data to a woman in a medical setting.

How Dr Paul Alsop reviews the quality of his skin cancer work

Every skin lesion that Dr Paul Alsop biopsies or removes is sent to an independent laboratory (Pathlab) for histopathological analysis. These results are reviewed regularly to ensure skin cancers are detected accurately and removed safely.

What was reviewed

  • 813 diagnostic skin lesions over a 12-month period

  • Each lesion counted once using the laboratory accession number

  • Results based entirely on independent pathology data

Key results

  • 47% of lesions removed were cancer or pre-cancer

  • 33 melanomas were diagnosed

  • On average, 25 lesions were assessed for each melanoma found

For comparison:

  • Many general practices assess 30–50 lesions per melanoma

  • Specialist skin cancer clinics typically report 20–30 lesions per melanoma

Cancer removal and margins

  • 21 post-excision clearance specimens were recorded

  • This equates to approximately 5–6% of cancer cases requiring planned follow-up

For context:

  • General practice reports incomplete excision rates of 8–30%

  • Specialist skin cancer services typically report 2–5%

What this means for patients

These results reflect a selective, risk-based approach:

  • Important skin cancers are identified at a high rate

  • Melanoma detection is efficient and appropriate

  • Most cancers are fully removed at the first procedure

“I favour conservative, risk-based decision-making over routine excision of uncertain lesions. Independent pathology audit shows that most lesions removed are clinically significant, supporting careful selection rather than “cutting to be safe”.”
— Dr Paul Alsop

For Clinicians

Two male doctors chatting in a hospital room, one in scrubs and the other in a white lab coat with a stethoscope.

Independent histopathology audit — accession-level analysis

Data source: Pathlab histopathology export (.txt)
Audit unit: Unique pathology accession number (one specimen = one case)
Reporting basis: Independent laboratory data (not self-reported)

Dataset structure

  • Total accessions reviewed: 835

  • Diagnostic specimens included: 813

  • Post-excision clearance specimens: 21

Clearance specimens were analysed separately and excluded from diagnostic performance metrics.

Classification methodology

  • Lesion category assigned solely from the final Diagnosis field

  • Clinical indication, narrative, and microscopy text excluded

  • Each specimen assigned to a single diagnostic category

  • Actinic keratoses (AK) reported but excluded from primary B:M ratios

This approach prevents diagnostic inflation and ensures reproducibility.

Diagnostic yield and case mix

Among 813 diagnostic specimens:

  • 384 malignant / pre-malignant lesions

  • 429 benign lesions

This corresponds to:

  • 47% malignant / pre-malignant

  • 53% benign

This represents a cancer-weighted workload.

Comparator context (percentage malignant):

  • General GP practice: ~10–25%

  • Mixed-interest skin practice: ~25–35%

  • GPwSI / primary care skin cancer clinics: ~35–50%

  • This audit: 47%

Benign-to-malignant ratio (AK excluded)

Definitions:

  • Malignant: BCC, SCC (including SCC in situ), melanoma

  • Benign: all remaining diagnoses

  • Excluded: AK, post-excision clearance specimens

Result:

  • Benign-to-malignant ratio ≈ 1.05 : 1

Comparator context:

  • General GP practice: ~3–6 : 1

  • Mixed-interest skin work: ~1.5–3 : 1

  • GPwSI / primary care skin cancer clinics: ~1–2 : 1

  • Dermatology outpatient series: ~0.6–1.5 : 1

Melanoma detection efficiency

  • 33 melanomas diagnosed

  • ~25 diagnostic lesions per melanoma

Comparator context:

  • Opportunistic / non-dermoscopy practice: often >30–40 : 1

  • Modern dermoscopy-guided practice: ~20–50 : 1

Post-excision clearance and margin management

  • 21 post-excision clearance specimens

  • Equivalent to ~5–6% of malignant cases

Clearance specimens were:

  • Explicitly counted

  • Reported transparently

  • Excluded from diagnostic yield and B:M calculations

Comparator context (reported incomplete or planned re-excision rates):

  • General practice: ~8–30%

  • GPwSI / dermatology / plastic surgery series: ~2–5%

Interpretation

  • Diagnostic workload is cancer-weighted and dominated by non-melanoma skin cancer

  • Diagnostic specificity is maintained at higher volume

  • Melanoma detection efficiency is appropriate

  • Margin management is structured, explicit, and within specialist ranges

Methodological strengths

  • Accession-based analysis

  • Independent pathology source

  • Explicit inclusion and exclusion criteria

  • Separation of diagnostic vs post-treatment specimens

  • Fully reproducible from raw Pathlab exports

Summary

This audit demonstrates a malignant-dominant diagnostic case mix, efficient melanoma detection, and specialist-level margin management, using transparent, conservative, and reproducible methodology suitable for peer scrutiny and longitudinal audit.

“Pathology audit findings are consistent with a high-threshold, oncology-focused approach to lesion management, prioritising diagnostic yield and surgical quality over volume.”
— Dr Paul Alsop

Comparator data are included for contextual reference only and should not be interpreted as formal benchmarks, thresholds, or indicators of clinical performance.

Data analysis was performed with the use of raw data processed manually in MS Excel, then verified with reproduciable AI data prompts:

“Analyse a raw Pathlab histopathology export (.txt) using specimen-level analysis.
Use the laboratory accession number as the unique unit of analysis (one specimen = one case).
Classify lesions strictly from the final Diagnosis field only; ignore narrative history, microscopy text, and clinical indication fields.
Group diagnoses into: basal cell carcinoma (BCC), squamous cell carcinoma (including SCC in situ), melanoma (in situ and invasive), actinic keratosis (AK), benign melanocytic lesions, other benign lesions, and post-excision clearance specimens.
Exclude AK-only specimens from primary benign-to-malignant ratio calculations.
Count post-excision clearance specimens separately and exclude them from diagnostic yield metrics.
Calculate absolute counts, benign-to-malignant ratios (with and without AK), percentage malignant, lesions-per-melanoma ratio, and first-pass complete excision rate based on margin status where applicable.
Do not infer diagnoses from partial text or assumptions.
Return results as reproducible summary metrics consistent with independent pathology audit methodology.”

References

  1. SCARD Systems.
    Report for the SCARD Research Pool.
    Reporting period: 1 Feb 2025 – 16 Feb 2026.
    (287 clinicians; 121,929 lesions)

  2. Murchie P, et al.
    Diagnostic accuracy of skin cancer excisions in primary care: a retrospective observational study.
    British Journal of General Practice. 2011;61:e563–e569.

  3. Goulding JMR, et al.
    The accuracy of skin cancer excision by general practitioners in primary care.
    British Journal of Dermatology. 2001;145:884–888.

  4. Reid CM, et al.
    Skin cancer management by general practitioners with advanced training.
    Medical Journal of Australia. 2010;193(6):328–332.

  5. Roozeboom MH, et al.
    Incomplete excision of basal cell carcinoma: a systematic review.
    British Journal of Dermatology. 2012;167:353–361.

  6. Bath-Hextall FJ, et al.
    Surgical excision versus other treatments for basal cell carcinoma.
    British Journal of Dermatology. 2007;156:848–857.

  7. Rowe DE, Carroll RJ, Day CL.
    Long-term recurrence rates in previously untreated basal cell carcinoma.
    Journal of the American Academy of Dermatology. 1989;21(5):756–764.

  8. Leffell DJ, et al.
    Surgical treatment of nonmelanoma skin cancer.
    New England Journal of Medicine. 2001;345:976–983.

  9. Hallock A, et al.
    Audit of skin lesion excision and diagnostic yield in primary care.
    British Journal of Dermatology.

  10. English DR, et al.
    Incidence of cutaneous melanoma and diagnostic accuracy in primary care.
    Medical Journal of Australia.

  11. Australian Skin Cancer Audit Research Database (SCARD).
    SCARD Research Pool Outcomes Report.

  12. Australian Skin Cancer Audit Research Database (SCARD).
    SCARD Methods and Definitions Document.