Can a Family Doctor Perform Punch Biopsy for Suspected Melanoma?
No, family doctors should not perform punch biopsies for suspected melanoma in primary care settings. 1, 2
The Evidence Against Punch Biopsy in Primary Care
The UK guidelines explicitly state that "there is no place for incisional biopsy in primary care" when melanoma is suspected, and punch biopsy falls into this category of partial sampling techniques. 1 This prohibition exists because:
Punch biopsies make pathological staging impossible in the majority of cases, preventing accurate measurement of Breslow thickness, which is the single most critical prognostic factor. 1
Only 45% of punch biopsies successfully obtained Breslow thickness in one audit, demonstrating their inadequacy for proper melanoma assessment. 3
Punch biopsies should only be performed by specialists within a skin cancer multidisciplinary team, not in primary care, and only in highly select circumstances such as facial lentigo maligna, acral melanoma, or very large lesions where complete excision is not feasible. 2
What Family Doctors Should Do Instead
The appropriate action is urgent referral without biopsy. 1 Specifically:
Refer patients with suspicious pigmented lesions urgently to a dermatologist or surgeon/plastic surgeon with expertise in pigmented lesions. 1
Ensure the patient is seen within 2 weeks of the referral letter. 1
Do not attempt biopsy in primary care - even when melanoma is suspected, the family doctor should refer without performing any biopsy procedure. 1, 2
The Preferred Biopsy Technique (When Performed by Specialists)
When specialists perform biopsies for suspected melanoma, the gold standard is:
Narrow excisional/complete biopsy with 1-3 mm margins that includes the entire lesion as a full-thickness specimen extending into subcutaneous fat. 1, 2, 4
This can be accomplished through fusiform/elliptical excision, punch excision (removing the entire lesion), or deep shave/saucerization. 2, 4
Critical Pitfalls to Avoid
Do not perform superficial shave biopsies or standard punch biopsies in primary care when melanoma is suspected - these techniques underestimate Breslow thickness and clinical stage, leading to inadequate treatment planning. 2, 4
Do not delay referral to perform a biopsy - the audit data shows that 48% of GP referrals appropriately came without biopsy, while 30% inappropriately had punch, shave, or even curettage biopsies performed. 3
Recognize that even when performed by specialists, punch biopsies have high upstaging rates - meaning the initial biopsy underestimates the true depth and stage of the melanoma. 2