Abstract
The COVID-19 pandemic has had a profound impact on the provision of skin cancer treatment in the UK. To preserve the service, the department transformed the outpatient skin cancer clinic into teleclinic service. This study examines the safety and efficacy of a teleclinic consultation, in comparison to a face-to-face consultation. We assessed efficacy in terms of accuracy of the clinical diagnosis in comparison to the histopathological result and whether treatment was designated the appropriate clinical priority/urgency.
A total of 120 lesions in 98 patients were assessed, 55 patients in the face-to-face clinic cohort, and 43 patients in the teleclinic cohort. Diagnostic accuracy was better in face-to-face clinic compared to teleclinic; 85.0% and 63.6% respectively (χ2 (1, N = 120) = 7.35, p = 0.0067). The accuracy of listing patients on the correct pathway was slightly higher for teleclinic patients. Of the teleclinic patients listed through the urgent pathway, 45.7% justified their urgent status, compared with 37.5% of those listed urgent in face-to-face clinic (p = 0.67). For those listed as routine, 100% of teleclinic patients were listed appropriately whereas the accuracy was 96.8% for the face-to-face clinic counterpart.
In conclusion, despite teleclinic having slightly reduced diagnostic accuracy, teleclinics show comparable accuracy in listing patients to urgent or routine skin cancer pathways. It offers convenience to patients in addition to reducing time to treatment and cost effectiveness. The lessons learned in the pandemic can be applied to the post-COVID healthcare environment.
Dear Sir
Introduction
The COVID-19 pandemic has had a profound impact on the provision of skin cancer treatment in the UK.1 To preserve the service, avoid diagnostic and treatment delays, whilst minimising patient exposure and risk of contracting COVID, the department transformed the outpatient skin cancer clinic into teleclinic service. This study examines the safety and efficacy of a teleclinic consultation, in comparison to a face-to-face consultation, in the assessment and surgical planning for patients referred to plastic surgeons with suspected skin cancer.
Methods
The study examined consecutive patients referred to a single plastic surgery consultant with a new suspected skin malignancy, assessed in consultations that took place in April-July 2020 (teleclinic consultations), or during the corresponding period in 2019 (face-to-face consultations). Patients were included in the study where a clinical diagnosis of skin cancer was made in the initial clinic appointment, and the patient listed for surgery through either the urgent (squamous cell carcinoma [SCC]/melanoma) or routine (basal cell carcinoma [BCC]) skin cancer pathways. Data was obtained from the electronic patient records (electronic document management system [EDMS]), examining clinic letter, the surgical procedure listing form, the operation note and histology report. Diagnostic accuracy was determined by comparing clinical diagnosis at the time of outpatient clinic with the histological diagnosis. Accuracy of surgical planning was evaluated as the proportion of patients correctly designated into the urgent or routine clinical pathways, as appropriate to their histological diagnosis. Chi-square test was used to determine statistical significance.
Results
The COVID-19 pandemic had an impact upon the number of new skin cancer referrals, and how the proportion of consultations were performed face to face or remotely (Figure 1 ). A total of 120 lesions in 98 patients were assessed, 55 patients in the face-to-face clinic cohort, and 43 patients in the teleclinic cohort. Demographic characteristics between the two cohorts were similar, with an average age of 71.8 ± 14.4 years and mostly Caucasian ethnicity (Table 1 ).
Figure 1.
Trend in distribution of new referrals in assessed in teleclinic and face-to-face clinic during COVID-19 pandemic.
Table 1.
Demographic characteristics of study participants (n = 98; n = 55 in face-to-face clinic and n = 43 in teleclinic) and index lesions (n = 120; 60 in each cohort).
| Characteristic | Face-to-face clinic No. (%) | Teleclinic No. (%) |
|---|---|---|
| Sex٭ | ||
| Male | 21 (48.8) | 31 (56.4) |
| Female | 22 (51.2) | 24 (43.6) |
| Mean age, y [SD]٭ | 71.0 [14.5] | 72.4 [14.3] |
| Ethnicity٭ | ||
| White British | 41 (95.3) | 40 (72.7) |
| Other | 0 (0.0) | 1 (1.8) |
| Not stated | 2 (4.7) | 14 (25.5) |
| Lesion locationᶧ | ||
| Head / neck | 46 (76.7) | 37 (61.7) |
| Hand / arm / shoulder | 6 (10.0) | 12 (20.0) |
| Trunk | 5 (8.3) | 3 (5.0) |
| Leg / foot | 3 (5.0) | 8 (13.3) |
| Place of referral٭ | ||
| Dermatology | 23 (53.5) | 39 (70.9) |
| General Practice | 19 (44.2) | 10 (18.2) |
| Skin Cancer Nurse | 1 (2.3) | 5 (9.1) |
| Other | 0 (0.0) | 1 (1.8) |
| Skin cancer pathway listing٭ | ||
| Urgent | 8 (18.6) | 46 (83.6) |
| Routine | 31 (72.1) | 9 (16.4) |
| Not stated | 4 (9.3) | 0 (0.0) |
| Procedure performeda | ||
| Excision biopsy | 39 (65.0) | 49 (81.7) |
| Incision biopsy | 21 (35.0) | 11 (18.3) |
| Histopathological diagnosisa | ||
| Malignant | 47 (78.3) | 39 (65) |
| Basal cell carcinoma | 42 (70.0) | 17 (28.3) |
| Squamous cell carcinoma | 4 (6.7) | 20 (33.3) |
| Basosquamous carcinoma | 1 (1.7) | 1 (1.7) |
| Lentigo malignant melanoma | 0 | 1 (1.7) |
| Non-malignant | 13 (21.6) | 21 (35) |
| Bowen's disease | 1 (1.7) | 2 (3.3) |
| Actinic keratosis | 2 (3.3) | 3 (5.0) |
| Othersb | 10 (16.7) | 16 (26.7) |
| Urgent (SCC/melanoma) | 4 (6.7) | 21 (35) |
| Routine (BCC/benign) | 56 (93.3) | 39 (65) |
Denominator is number of participants.
Denominator is number of lesions.
All benign lesions.
In comparison with face-to-face clinics, teleclinics comprised a lower proportion of patients with malignant lesions (65% versus 78.3%). The majority of cancers seen in face-to-face clinics were BCC (89%). There was a higher proportion of patients referred to teleclinic with SCC/melanoma (35%) in comparison to face to face (6.7%).
Diagnostic accuracy was better in face-to-face clinic compared to teleclinic; 85.0% and 63.6% respectively (χ2 (1, N = 120) = 7.35, p = 0.0067). The diagnostic accuracy in teleclinic of lesions accompanied by photographs was slightly higher (66.7%) than those that did not (58.3%); however, this does not show statistically significant difference.
Teleclinic listed a higher proportion of patients to the urgent skin cancer pathway compared with face-to-face clinic (83.6% cf. 18.6%). The accuracy of listing patients on the correct pathway was also slightly higher for teleclinic patients. Of the teleclinic patients listed through the urgent pathway, 45.7% justified their urgent status, compared with 37.5% of those listed urgent in face-to-face clinic (p = 0.67). For those listed as routine, 100% of teleclinic patients and 96.8% of face-to-face clinic patients were listed appropriately.
More lesions (10.0%) listed via teleclinic had an “on the day” change in the nature of the surgical procedure from that anticipated in the initial listing form, compared with lesions listed via face-to-face (1.7%).
Discussion
The overall diagnostic accuracy for face-to-face consultation was higher than for teleclinic consultations, which is in agreement with most published studies.2, 3, 4 Our results demonstrate that the accuracy of listing patients to the appropriate skin cancer pathway was similar between the two groups. Teleclinic substantially overestimated skin lesions to be urgent yet this did not occur to any greater extent than in face-to-face. Clinicians may be anxious about downgrading a potential SCC and delaying treatment. The overestimation in teleclinic was actually slightly lower than in face-to-face clinic, but this could in part reflect the higher proportion of patients presenting to teleclinic with SCC/melanoma during this period. In both groups the accuracy of routine booking is very high. There were no patients listed through teleclinics as routine pathway which turned out to be urgent.
During the pandemic the average number of days from referral to surgery did not increase and was within guidelines; 16.9 ± 15.1 and 70.3 ± 30.3 days for urgent and routine pathways, respectively. Indeed, digital image referral for skin malignancy has been reported to reduce the interval between referral and diagnosis.5
In conclusion, despite teleclinic having slightly reduced diagnostic accuracy, teleclinics show comparable accuracy in listing patients to urgent or routine skin cancer pathways. It offers convenience to patients in addition to reducing time to treatment and cost effectiveness. The lessons learned in the pandemic can be applied to the post-COVID healthcare environment.
Ethical approval
n/a.
Declaration of Competing Interest
none
Funding
n/a.
References
- 1.Nolan G.S., Dunne J.A., Kiely A.L., Pritchard Jones R.O., Gardiner M., RSTNCOVID: Skin Collaborative. Jain A., Nolan G.S. The effect of the COVID-19 pandemic on skin cancer surgery in the United Kingdom: a national, multi-centre, prospective cohort study and survey of Plastic Surgeons. Br J Surg. 2020;107(12):e598–e600. doi: 10.1002/bjs.12047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Chuchu N., Dinnes J., Takwoingi Y., Matin R.N., Bayliss S.E. Teledermatology for diagnosing skin cancer in adults. Cochrane Database Syst Rev. 2018;12(12) doi: 10.1002/14651858.CD013193. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Finnane A., Dallest K., Janda M., Soyer P. Teledermatology for the diagnosis and management of skin cancer. A systematic review. JAMA Dermatol. 2017;153(3):319–327. doi: 10.1001/jamadermatol.2016.4361. [DOI] [PubMed] [Google Scholar]
- 4.Wolner Z.J., Yélamos O., Liopyris K., Rogers T., Marchetti M.A., Marghoob A.A. Enhancing skin cancer diagnosis with dermoscopy. Dermatol Clin. 2017;35(4):417–437. doi: 10.1016/j.det.2017.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tadros A., Murdoch R., Stevenson J.H. Digital image referral for suspected skin malignancy – a pilot study of 300 patients. J Plast Reconstr Aesthet Surg. 2009;62(8):1048–1053. doi: 10.1016/j.bjps.2008.02.005. [DOI] [PubMed] [Google Scholar]