To the Editor: Guidelines have been published regarding the management of cutaneous malignancy since the start of the COVID-19 pandemic.1 , 2 In addition, a recent report was published regarding a change in the volume of tumors treated in one dermatologic surgery unit due to the pandemic.3 However, no studies have further evaluated the impact of COVID-19 on the treatment of cutaneous malignancies by dermatologic surgeons. We studied the changes in demographics and surgical practices during the COVID-19 pandemic in one dermatologic surgery unit, where patients were prioritized based on the presence of high-risk features of cutaneous malignancies.4
We included patients seen in our dermatologic surgery unit for either Mohs surgery or excisions between April 28, 2020 and July 31, 2020 (offices were closed for 6 weeks prior to this time) and an equally sized, randomly selected comparator group of patients seen during the same months in 2019. We excluded patients whose procedures were converted to nonsurgical visits, patients who underwent diagnostic procedures, and patients with no previous biopsies. We extracted demographic information and tumor type for each patient. We collected information on the size of the final Mohs defect and the number of stages for Mohs surgery patients. We collected the final linear repair size for excisional surgery patients. Separate procedures on the same patient were analyzed separately. A Kruskal-Wallis test was used to compare the different groups by year. P values < .05 were considered statistically significant.
The total number of Mohs surgeries or excisions performed within the same months in 2019 was 1045 versus 418 in 2020. There were no statistically significant differences between the prepandemic and pandemic era in terms of demographic factors or type of procedure (Mohs surgery vs excision). Similarly, the average size of the final defect and the average number of stages were similar between the 2 groups for patients undergoing Mohs surgery. The average size of the linear repair was also similar for patients undergoing excisional surgery. However, there was a statistically significant difference in the type of neoplasms treated. During the pandemic, there was an increase in the squamous cell carcinomas treated, a decrease in the basal cell carcinomas treated, and a decrease in the invasive melanomas treated (P = .006; Table I ).
Table I.
Demographic and surgical characteristics of dermatologic surgery patients in the pre-pandemic era versus pandemic era
| 2019 | 2020 | P value | |
|---|---|---|---|
| Type of procedure, n | .07 | ||
| Mohs surgery | 283 | 259 | |
| Excisional surgery | 119 | 143 | |
| Mean age at time of procedure (SD), y | 68 (14.9) | 67 (14.4) | .35 |
| Number of non-english speaking patients, n | 10 (1 Albanian, 1 ASL, 1 Cape Verdean, 1 Mandarin, 1 Portuguese, 3 Russian, 1 Spanish, 1 Vietnamese) | 8 (1 Albanian, 6 Russian, 1 Spanish) | .63 |
| Highest level of education, n | .54 | ||
| 8th grade or less | 4 | 0 | |
| Some high school | 3 | 4 | |
| Graduated from high school or obtained my General Educational Development Test | 60 | 45 | |
| Some college/vocational/technical program | 50 | 60 | |
| Graduate from college, graduate, or postgraduate school | 247 | 255 | |
| Unknown | 38 | 38 | |
| Type of tumor, n | .006 | ||
| BCC | 193 | 155 | |
| SCC | 160 | 185 | |
| Invasive melanoma | 9 | 6 | |
| MMIS | 8 | 7 | |
| Dysplastic nevus | 28 | 43 | |
| Other (AFX, PDS, pyogenic granuloma, EMPD, MAC, porocarcinoma) | 4 | 6 | |
| Average size of Mohs defect, cm2 | 3.21 | 3.31 | .77 |
| Average number of Mohs stages | 1.7 | 1.6 | .47 |
| Average size of linear excisions, cm | 5.0 | 5.4 | .05 |
AFX, Atypical fibroxanthoma; BCC, basal cell carcinoma; EMPD, extramammary Paget's disease; MAC, microcystic adnexal carcinoma; MMIS, malignant melanoma in situ; PDS, pleomorphic dermal sarcoma; SCC, squamous cell carcinoma, SD, standard deviation.
We prioritized surgery for cutaneous lesions with high-risk features upon reopening, including squamous cell carcinomas over basal cell carcinomas, given the higher likelihood for metastasis.4 Despite this, however, the treatment of patients during the pandemic resulted in similar final Mohs defect sizes, number of Mohs stages, and linear repair sizes. Our findings stand in contrast to a study that assessed non-melanoma skin cancer in a plastic surgery clinic, which found that the tumors removed in 2020 were larger compared to prior years.5 This difference may be due to the differences in triage or surgical factors given the lack of skin-conserving modalities, such as Mohs surgery.
Study limitations include a small sample size from a single academic institution. Nonetheless, our findings demonstrate that the triage in our dermatologic surgery unit during the COVID-19 pandemic resulted in a different mix of tumor types but did not impact the demographic breakdown of patients or surgical complexity of cases. Further work is needed to understand the long-term impact of triage during the COVID-19 pandemic on dermatologic surgery outcomes.
Conflicts of interest
The authors declare no relevant conflicts of interest.
Footnotes
Funding Sources: None.
IRB approval status: This study was granted an exemption from review by the Dana Farber Cancer Institution Institutional Review Board.
References
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