Reduction in skin cancer diagnosis, and overall cancer referrals, during the COVID‐19 pandemic

Dear Editor, The COVID‐19 pandemic has led to a marked reduction in the number of patients accessing the UK’s National Health Service for emergency reasons.¹ The cause for this decline is as yet unknown, and it is likely to be multifactorial. We investigated whether there had been a similar reduction in urgent cancer referrals – known in England as the two‐week wait (TWW) pathway – and subsequent diagnosis of skin cancer in our dermatology service.

Malignant melanoma (MM) is the fifth most common cancer in the UK.² Cutaneous squamous cell carcinoma (SCC) also has a significant risk of mortality.³ The early diagnosis of MM and SCC is critical to improving patient survival,⁴ a principle that applies to all cancers.

The number of TWW referrals our department has received over the past 5 years has increased (Figure 1a). Using our cancer tracking database, we identified a dramatic 34·3% reduction in referrals in February to April 2020 compared with the same period in 2019 (Figure 1b). The largest decrease was in April 2020, with 335 TWW referrals received, which was 56·4% lower than in April 2019 (768).

Figure 1.

Skin cancer referrals and diagnoses dropped in the period of February to April 2020. (a) Increasing trend of two‐week wait (TWW) referrals over the last 5 years. (b) The number of referrals made from February to April 2020 compared with the same period in previous years. (c) The number of skin cancer diagnoses among referred patients in March 2020 compared with previous years. (d) The number of TWW referrals across a range of specialties in our hospital in April 2020 compared with April 2019.

More concerning is that the number of skin cancers diagnosed in patients referred on the TWW pathway in March 2020 was lower than in previous years (28 in March 2020, 52 in March 2019; Figure 1c). Using our average conversion rate (percentage of TWW referrals with a histological diagnosis of skin cancer) over the last 5 years (6·95%), and based on the average increase in referrals, we expected to diagnose 125 MMs and SCCs in March and April 2020. Assuming the conversion rate remains stable, this number will drop to 59, a 53% reduction. The reduction in referrals and subsequent skin cancer diagnoses in our patient population is a major concern. Ultimately, many of these cases may present with more advanced disease and poorer outcomes as a consequence.

We investigated whether this trend was observed across a range of other TWW cancer referral pathways in our hospital. We report here the same concerning pattern of decreased referrals across a wide variety of cancer types (Figure 1d).

During the post‐COVID pandemic recovery phase there may be a significant rebound wave of TWW skin cancer referrals to dermatology departments across the country. This may further test already stretched resources. Predicting this peak will enable advance planning of the provision of appropriate clinic capacity and associated levels of staffing.

The detrimental consequences of the COVID‐19 pandemic to clinical practice will not be understood for some time to come. These findings are a wake‐up call to prepare for an upswing in skin cancer referrals later this year. The findings also suggest this trend in referrals may lead to delayed diagnosis, with poorer prognosis, of a wide range of cancers.

Acknowledgments

We would like to thank David Muskett, Andrew Gardner and Rebecca Thompson for assisting with data collection from the histopathology labs, and the Cancer Tracking Service at Salford Royal Hospital.

Author Contribution

Charles H Earnshaw: Formal analysis (lead); Writing‐original draft (lead); Writing‐review & editing (equal). Hamish John, Alexander Hunter: Conceptualization (equal); Supervision (equal); Writing‐review & editing (equal). Emma McMullen: Conceptualization (equal); Supervision (equal); Writing‐review & editing (equal). Christopher Ernest, Maitland Griffiths: Supervision (equal); Writing‐review & editing (equal). Richard B Warren: Conceptualization (equal); Supervision (equal); Writing‐review & editing (equal).