To the Editor: The COVID-19 pandemic has had a significant impact on cancer care.1 Some have projected up to a 10% increase in mortality for specific malignancies due to delays in care caused by the COVID-19 pandemic, but the pandemic's impact on melanoma has yet to be defined.2 , 3 Delays in diagnosis could result in thicker melanomas at presentation and profound effects on patient outcomes. This study evaluates the presentation status of melanoma lesions before and after a period of pandemic restrictions, which limited dermatologic evaluation to define the pandemic's impact on melanoma care.
Patients referred to the University of Pennsylvania's Dermatopathology Department for pathologic slide review and/or Division of Endocrine and Oncologic Surgery (handling most of the institutional resection volume) for definitive resection of nonmetastatic primary melanomas were identified from a 2-month period after clinical resurgence at our institution (June 15-August 15, 2020; the COVID-19 era cohort) and a corresponding period in the pre–COVID-19 era (June 15-August 15, 2019). Patient and tumor characteristics were analyzed by univariate analyses. All tests were 2-sided, and P values less than .05 were considered statistically significance. Analyses were performed in Stata for Windows version 16.1.
Of all melanomas evaluated at our institution, 358 and 298 patients were evaluated in the pre–COVID-19 era cohort and COVID-19 era cohort, respectively. There were no differences in patient characteristics and tumor type (invasive melanoma versus melanoma in situ) between the 2 cohorts. After exclusion of melanoma in situ lesions, 172 and 153 patients with invasive melanoma were evaluated in the pre–COVID-19 and COVID-19 era cohorts, respectively (Table I ). Patients in the COVID-19 era cohort were more likely to have satellitosis (3.9% vs 0%, P = .001) compared with pre–COVID-19 era patients. Among patients evaluated by the oncologic surgery department, specifically, COVID-19 era (N = 56) patients had higher median tumor Breslow depth (1.4 mm vs 0.87 mm; P = .013) and a higher proportion of patients with mitotic count greater than 1/mm2 (58.9% vs 35.3%; P = .018), satellitosis (8.9% vs 0%; P = .029), and pT3/pT4 tumors (35.7% vs 19.1%; P = .037) compared with pre–COVID-19 era patients (N = 68) (Table II ).
Table I.
Patient and tumor characteristics of all melanomas examined by dermatopathology and oncologic surgery from June 15 to August 15, 2019 and June 15 to August 15, 2020
| Pre–COVID-19 |
COVID-19 |
P value | |
|---|---|---|---|
| N = 172 (52.9%) | N = 153 (47.1%) | ||
| Age (median, IQR) | 68 (16.5) | 68 (18) | .518 |
| <50 y | 24 (14.0) | 23 (15.0) | |
| 50-59 y | 22 (12.8) | 30 (19.6) | |
| 60-69 y | 48 (27.9) | 38 (24.8) | |
| 70-79 y | 56 (32.6) | 43 (28.1) | |
| ≥80 y | 22 (12.8) | 19 (12.4) | |
| Sex | .757 | ||
| Male | 96 (55.8) | 88 (57.5) | |
| Female | 76 (44.2) | 65 (42.5) | |
| Race | .257 | ||
| White | 138 (80.2) | 116 (75.8) | |
| Black | 2 (1.2) | 0 (0.0) | |
| Asian | 0 (0.0) | 1 (0.7) | |
| Unknown | 32 (18.6) | 36 (23.5) | |
| Immune compromise | 1 (0.6) | 4 (2.6) | .137 |
| Tumor depth (median, IQR) | 0.5 (0.7) | 0.6 (0.9) | .171 |
| pT staging group | .900 | ||
| 1/2 | 147 (85.5) | 130 (85.0) | |
| 3/4 | 25 (14.5) | 23 (15.0) | |
| Clark level | .880 | ||
| Level II | 57 (33.1) | 47 (30.7) | |
| Level III | 52 (30.2) | 41 (26.8) | |
| Level IV | 56 (32.6) | 58 (37.9) | |
| Level V | 4 (2.3) | 4 (2.6) | |
| Unknown | 3 (1.7) | 3 (2.0) | |
| Lymphovascular invasion | 6 (3.5) | 4 (2.6) | .092 |
| Unknown | 5 (2.9) | 0 (0.0) | |
| Ulceration | 14 (8.1) | 22 (14.4) | .165 |
| Unknown | 3 (1.7) | 4 (2.6) | |
| Tumor-infiltrating lymphocytes | .537 | ||
| Brisk | 18 (10.5) | 14 (9.2) | |
| Nonbrisk | 92 (53.5) | 88 (57.5) | |
| Unknown | 28 (16.3) | 17 (11.1) | |
| Vertical growth | 114 (66.3) | 98 (64.1) | .673 |
| Unknown | 8 (4.7) | 5 (3.3) | |
| Regression | 48 (27.9) | 32 (20.9) | .162 |
| Unknown | 4 (2.3) | 8 (5.2) | |
| Satellitosis | 0 (0.0) | 6 (3.9) | .001∗ |
| Unknown | 5 (2.9) | 14 (9.2) | |
| Perineural invasion | 3 (1.7) | 4 (2.6) | .080 |
| Unknown | 8 (4.7) | 1 (0.7) | |
| Mitotic count | .240 | ||
| None | 97 (56.4) | 79 (51.6) | |
| ≤1 | 33 (19.2) | 24 (15.7) | |
| >1 | 42 (24.4) | 50 (32.7) | |
| Residual tumor | 50 (29.1) | 47 (30.7) | .691 |
| Unknown | 58 (33.7) | 56 (36.6) | |
| Source | .587 | ||
| Dermatopathology only | 104 (60.5) | 97 (63.4) | |
| Surgery | 68 (39.5) | 56 (36.6) |
IQR, Interquartile range.
Indicates significance.
Table II.
Patient and tumor characteristics of all melanomas examined by oncologic surgery from June 15 to August 15, 2019 and June 15 to August 15, 2020
| Pre–COVID-19 |
COVID-19 |
P value | |
|---|---|---|---|
| N = 68 (54.8%) | N = 56 (45.2%) | ||
| Age (median, IQR) | 65 (19) | 66.5 (14.5) | .699 |
| <50 y | 11 (16.2) | 7 (12.5) | |
| 50-59 y | 10 (14.7) | 12 (21.4) | |
| 60-69 y | 22 (32.4) | 17 (30.4) | |
| 70-79 y | 18 (26.5) | 17 (30.4) | |
| ≥80 y | 7 (10.3) | 3 (5.4) | |
| Sex | .504 | ||
| Male | 36 (52.9) | 33 (58.9) | |
| Female | 32 (47.1) | 23 (41.1) | |
| Race | .085 | ||
| White | 59 (86.8) | 54 (96.4) | |
| Black | 2 (2.9) | 0 (0.0) | |
| Asian | 0 (0.0) | 1 (1.8) | |
| Unknown | 7 (10.3) | 1 (1.8) | |
| Immune compromise | 0 (0.0) | 3 (5.4) | .053 |
| Tumor depth (median, IQR) | 0.8 (1.0) | 1.4 (3.0) | .013∗ |
| pT staging group | .037∗ | ||
| 1/2 | 55 (80.9) | 36 (64.3) | |
| 3/4 | 13 (19.1) | 20 (35.7) | |
| Clark level | .006∗ | ||
| Level II | 14 (20.6) | 3 (5.4) | |
| Level III | 23 (33.8) | 11 (19.6) | |
| Level IV | 28 (41.2) | 36 (64.3) | |
| Level V | 3 (4.4) | 3 (5.4) | |
| Unknown | 0 (0.0) | 3 (5.4) | |
| Lymphovascular invasion | 0 (0.0) | 2 (3.6) | .130 |
| Unknown | 2 (2.9) | 0 (0.0) | |
| Ulceration | 12 (17.7) | 15 (26.8) | .327 |
| Unknown | 1 (1.5) | 0 (0.0) | |
| Tumor-infiltrating lymphocytes | .764 | ||
| Brisk | 11 (16.2) | 6 (10.7) | |
| Nonbrisk | 38 (55.9) | 36 (64.3) | |
| Unknown | 10 (14.7) | 7 (12.5) | |
| Vertical growth | 50 (73.5) | 46 (82.1) | .492 |
| Unknown | 6 (8.8) | 4 (7.1) | |
| Regression | 24 (35.3) | 12 (21.4) | .239 |
| Unknown | 1 (1.5) | 1 (1.8) | |
| Satellitosis | 0 (0.0) | 5 (8.9) | .029∗ |
| Unknown | 1 (1.5) | 0 (0.0) | |
| Perineural invasion | 2 (2.9) | 3 (5.4) | .734 |
| Unknown | 2 (2.9) | 1 (1.8) | |
| Mitotic count | .018∗ | ||
| None | 29 (42.7) | 12 (21.4) | |
| ≤1/mm2 | 15 (22.1) | 11 (19.6) | |
| >1/mm2 | 24 (35.3) | 33 (58.9) | |
| Residual tumor | 24 (35.3) | 24 (42.9) | .390 |
| Pathologic stage | .183 | ||
| I | 51 (75.0) | 34 (60.7) | |
| II | 13 (19.1) | 13 (23.2) | |
| III | 4 (5.9) | 9 (16.1) | |
| SLNB performed | 44 (64.7) | 45 (80.4) | .054 |
| Positive SLN | 3 (4.4) | 5 (8.9) | .308 |
IQR, Interquartile range; SLN, sentinel lymph node; SLNB, sentinel lymph node biopsy.
Indicates significance.
During the COVID-19 pandemic, to reallocate clinical resources and control viral transmission, outpatient health care services were limited for patients from March to mid-June. We investigated whether absence of routine dermatologic evaluation during this time resulted in advanced tumor presentation status after clinical resurgence. There was no difference noted in median thickness or pT staging group in melanomas evaluated overall. Among surgical patients specifically, there was an increase in median tumor depth, the proportion of pT3/pT4 lesions, and lesions with satellitosis. This finding may reflect a goal among clinicians to remove thin melanomas at clinics locally, minimizing the need for patient travel. The increase in median thickness of melanomas and absolute number of pT3/pT4 lesions (>50% increase) referred for surgical evaluation raises concerns for delay in diagnosis. Although this study is limited as a single-institution study over a short period, further study is warranted to better define the impact of the pandemic on melanoma care nationally.
Conflicts of interest
None disclosed.
Acknowledgments
The authors acknowledge support in part by the University of Pennsylvania Skin Disease Research Center (NIAMS P30-AR057217).
Footnotes
Funding sources: None.
IRB approval status: Not applicable.
Reprints not available from the authors.
References
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