Prolonged impact of COVID-19 pandemic on delayed melanoma diagnosis: further data based on one-year appraisal from Italy

To the editor:

The COVID-19 pandemic strongly affected health care organization in Italy, shifting resources from outpatients facilities for inpatient management; as expected, during lockdown, an increase in Breslow thickness and a reduction in new diagnoses of melanoma have been reported in a tertiary referral center in Rome;¹ also, outside Italy, Marson et al. reported a 43% decrease in melanoma diagnosis in the COVID period in the United States,² and Lallas et al. a 36.4% reduction in melanoma diagnosis in Greece.³ Papers about melanoma diagnosis delay based on a more prolonged period after lockdown are instead just a handful: a reduction in new diagnosis but no increase in Breslow thickness have been reported from March to October 2020 in Veneto region in northern Italy,⁴ whereas Lo Bello et al. compared data between March and December 2019 and March and December 2020 at a Como Hospital reporting an increase in Breslow thickness;⁵ the longest analysed interval was in Chile, describing a 31.2% reduction in the melanoma cases diagnosed per month between April 2020 and March 2021.⁶ We sought to analyse the impact of COVID-19 pandemic at a large referral hospital running four large healthcare districts in the Autonomous Province of Trento, Italy on melanoma diagnosis during a year from COVID-19 pandemic onset in Italy (i.e. from March 9 2020 to March 9 2021) with the same period before COVID-19 pandemic (i.e. from March 9 2019 to March 9 2020). Total melanoma diagnosis decreased from 401 (1,1 melanoma per day) to 246 (0.7 melanoma per day); no significant difference was found for age and sex. Breslow thickness increased significantly from 0,5±1,4 (mean±SD) to 0,9±2 (P=0,000), as well as the proportion of melanoma with Breslow thickness more than 1 millimeter i.e. those in need of sentinel lymph node biopsy, which significantly affects health care costs (Table 1).

After adjusting for confounding factors (age, gender, excision date in relation to COVID-19 pandemic) the period in which the excision was carried was a significant predictor of finding a thicker melanoma (i.e. with Breslow>1mm), all other factors being equal (Table 2).

Previous studies have been focused on melanoma diagnosis during the lockdown period. We instead analysed a longer period to fully capture the phenomenon amplitude. Further study is warranted to better define the impact of the pandemic on melanoma care nationally.

Table 1.

Summary data on patients.

	March 2019 - March 2020	March 2020 - March 2021	P
	(N=402)	(N=245)
Sex
Male	212	117	0.2
Female	190	128
Age (mean±SD)	59.4±17.3	60.8±17.7	0.26
median (range)	61(95)	64(97)
Breslow (mean±SD)	0.5±1.4	0.9±2	0.000
median (range)	0.2(12)	0.3(18)	0.004
≤1 mm (%)	363 (90,3)	185 (75.5)	0.000
>1 mm (%)	39 (9.7)	60 (24.5)
Ulceration
Ulcerated (%)	39 (9.7)	26 (10.6)	0.67
Not ulcerated (%)	354 (88.1)	209 (85.3)

SD, standard deviation.

Table 2.

Univariate and multivariate analyses (n=645) about Breslow thickness of melanoma.

	Breslow >1 vs. ≤1 mm			Breslow >1 vs. ≤1 mm
	Unadjusted			Adjusted
	OR	95% CI	P	OR	95% CI	P
Gender
Male	1.7	1.1-2.6	0.02	1.7	1.1–2.6	0.03
Female	-	-		-	–
Age	1.02	1.0-1.03	0.01	1.01	1.0-1.03	0.04
Excision date
March 2019 - March 2020	-	-	0.000	-	–	0.000
March 2020 - March 2021	3	1.9-4.6		3	1.93-4.74

OR, odds ratio; CI, confidence interval; SD, standard deviation.

Funding Statement

Funding: None.