Skin cancer and COVID‐19

Dear Editor,

Coronavirus disease (COVID‐19) emerged in Wuhan, China, in late 2019 and soon attained the status of a pandemic in early 2020. It primarily affects the respiratory system, often leading to multiple organ failure and death. ¹ The high infectivity of this virus with no definite treatment or vaccine yet has led to national lockdown and quarantine in various countries to flatten the curve forcing people to stay indoors. This has also affected the health care system with restricted footfall at regular hospital outpatient departments and private clinics.

This pandemic has altered every aspect of patient care, comprising both indoor and outdoor patients. Some of the worst affected patients include those with chronic illnesses like skin cancers (basal cell carcinoma, squamous cell carcinoma and melanoma). Due to minimal availability of public transport and doctors in regular clinics, several skin cancer patients are going undiagnosed, leading to delayed diagnosis resulting in worsening of its grade and prognosis. ² The ones already on treatment are finding it difficult to procure the medicines or attend hospitals for regular follow‐up.

Many patients with skin cancer are already immunosuppressed, thus increasing their susceptibility to various infections including COVID‐19. Besides, the severity and prognosis of COVID‐19 is poor in patients with comorbidities and immunosuppression. ³

Interestingly, some authors have reported the role of psychological stress in the pathogenesis of squamous cell carcinoma. ⁴ COVID‐19 is undoubtedly a stressful situation owing to limited knowledge regarding the nature of virus and lack of definite treatment. ⁵ Thus, COVID‐19‐induced stress may predispose patients to squamous cell carcinoma.

Newer anticancer molecules like immune checkpoint inhibitors (pembrolizumab, ipilimumab and nivolumab) are being used in melanoma ⁶ but there are reports of pembrolizumab‐induced neutropenia. ⁷ This weakens the immune system of patient leading to increased risk of COVID‐19. Thus, the risk:benefit ratio of a drug should be carefully evaluated, especially during such times. ⁸

The treatment regimens are also being modified to decrease the need of hospital visits by these patients to reduce the spread of COVID‐19, namely, pembrolizumab is being prescribed at 400 mg 6 weekly instead of 200 mg 3 weekly for cutaneous melanoma. ⁹

During such a health crisis with limited number of beds and shortage of anesthetists, continuation of surgery seems extremely difficult. COVID‐19‐related pneumonia in the postoperative period is a major risk and is most likely to prove fatal. Thus, invasive procedures such as biopsies and surgeries for all skin malignancies should be confined to only urgent cases. ⁹ In such times, dermoscopy may prove to be a valuable diagnostic tool, and invasive procedures may be postponed if feasible.

Another approach that can be universally adopted is to switch outpatient consults to online mode (teleconsultation) instead of a face‐to‐face interaction. This relieves the undue surge of patients in the hospital, ensures and enforces self‐quarantine and decreases the risk of exposure to patients as well as health care workers. ¹⁰ Face‐to‐face consultations, if needed, can be decided on case‐to‐case basis after the teleconsultation. For immunosuppressed cancer patients, a separate ward with a distinct set of doctors can be used who do not come in contact with COVID‐patients.

This pandemic has forced us to make drastic changes in our system of patient care, especially in case of chronic illnesses like cancers, it would be wise to learn from these changes and implement it in the future as well so that we are better prepared for such circumstances.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.