In this session, Dr Falk explains how melanoma, squamous cell carcinoma, basal cell carcinoma and rarer skin cancers raise distinct medico-legal questions around breach, prognosis and whether earlier intervention would truly have changed the outcome.

Watch the full webinar with Dr Stephen Falk here >

Skin Cancer Diagnosis: Clinical Risks

Skin cancer is common, but it does not always feature clearly in headline cancer statistics because many non-melanoma skin cancers have historically been excluded from registry data. Dr Falk explains that basal cell carcinoma and squamous cell carcinoma are often diagnosed early because they are visible, but this does not remove the risk of misdiagnosis, delayed referral or inappropriate reassurance.

Actinic keratoses, also known as solar keratoses, are often treated as benign sun-damaged skin changes. However, Dr Falk highlights that a significant proportion of squamous cell carcinomas may arise from these apparently benign lesions, creating a grey area for clinicians assessing whether biopsy or further review is needed.

Basal cell carcinoma and squamous cell carcinoma can also look clinically similar. This matters because their referral pathways and urgency may differ. Basal cell carcinomas are generally slower-growing and often fall outside two-week-wait cancer referral pathways, while squamous cell carcinomas are more likely to require urgent suspected cancer referral.

“Delay per se does not always cause trouble.”

Medico-Legal Considerations

The central medico-legal issue in many skin cancer claims is not simply whether there was a delay, but whether that delay made a material difference.

Dr Falk gives examples where breach may be accepted, but causation may still fail. In one case, a patient with squamous cell carcinoma of the ear was lost to follow-up and later developed a parotid metastasis. Although the failure to follow up was a breach, Dr Falk explained that follow-up would not necessarily have prevented the recurrence, the need for surgery, or the eventual outcome.

This distinction is essential for solicitors. A missed opportunity, administrative failure or delayed appointment may support breach, but expert oncology evidence is needed to determine whether earlier action would have altered:

• treatment options
• surgical extent
• metastatic progression
• prognosis
• life expectancy
• pain, suffering or treatment burden

Lead time bias is another important defence argument. Earlier diagnosis may mean the cancer is identified sooner, but this does not always mean the patient lives longer or avoids the same outcome. Dr Falk compares this to joining a train earlier on the route: the destination may remain unchanged.

“Lead time bias is a potent argument for defence in causation cases.”

Case Examples & Outcomes

Squamous Cell Carcinoma and Follow-Up Failure

Dr Falk discussed a case involving squamous cell carcinoma of the ear. The patient underwent excision with clear margins and should have received follow-up under national protocol, but was discharged. Several months later, he presented with a large parotid metastasis and required aggressive surgery and radiotherapy.

Although breach was agreed, causation failed because earlier follow-up would not necessarily have stopped the metastasis from occurring or avoided the treatment required.

Hand Lesion and Amputation

Another case involved a patient who presented with a lump on the hand. By the time the lesion was biopsied, it was an ulcerating squamous cell carcinoma requiring amputation below the elbow. Dr Falk explained that the cancer was already involving deeper tissues at an earlier stage, meaning the patient would likely have required amputation in any event.

Melanoma and Immunotherapy

Melanoma remains one of the most fertile areas for litigation, particularly where a suspicious pigmented lesion is repeatedly reassured as benign. However, Dr Falk explained that causation in melanoma claims has changed significantly due to modern immunotherapy.

Historically, metastatic melanoma had a very poor prognosis. Today, combination immunotherapy has transformed outcomes for many patients, meaning that claims once focused on major life expectancy loss may now be more limited to pain, suffering, treatment toxicity and psychiatric injury where the patient responds well.

“Melanoma has gone from being an almost universally fatal disease to, on balance, now a relatively curable disease.”

Rarer and Easily Missed Presentations

Dr Falk also highlighted several “catch” diagnoses, including acral melanoma presenting as a line in the nail, melanoma arising within pigmented foot lesions, and Marjolin’s ulcer, where squamous cell carcinoma develops in the site of an old scar or chronic wound. These examples reinforce the importance of careful clinical assessment, biopsy where appropriate, and safety-netting where a lesion changes or fails to resolve.

Key Takeaways for Solicitors

Skin cancer claims require careful separation of breach and causation. Even where the clinical pathway appears poor, causation may depend on tumour biology, staging, treatment options, metastatic timing and whether disease was already present but occult.

For solicitors reviewing potential claims, key questions include:

• Was the lesion appropriately assessed, photographed, biopsied or referred?
• Was the correct urgency applied to the referral pathway?
• Was there adequate safety-netting where a lesion was thought to be benign?
• Would earlier diagnosis have changed treatment or prognosis?
• Was metastatic disease likely already present at the time of the alleged breach?
• Has modern treatment, such as immunotherapy, altered the claimant’s prognosis?

Expert evidence should come from an oncologist with relevant experience in the cancer type involved. During the Q&A, Dr Falk explained that oncology has become increasingly site-specialist, and solicitors are on stronger ground where the instructed expert has treated the relevant type of cancer.

Skin cancer claims can involve complex questions of missed diagnosis, evolving treatment outcomes and causation uncertainty. Expert oncology evidence is essential in determining whether delay materially changed the outcome, or whether breach alone is insufficient to support the claim.