The impact of the COVID‐19 pandemic on diagnostic delay of skin cancer: a call to restart screening activities

Conflicts of interest

Dr. Garbe reports grants and personal fees from BMS, personal fees from MSD, grants and personal fees from NeraCare, grants and personal fees from Novartis, personal fees from Philogen, grants and personal fees from Roche, grants and personal fees from Sanofi, outside the submitted work. Dr Stratigos reports personal fees and/or research support from Novartis, Roche, BMS, Abbvie, Sanofi, Regeneron, Genesis Pharma, outside the submitted work. Dr Dessinioti has no conflict of interest to declare.

Funding sources

None.

To the Editor

The COVID‐19 pandemic has led to delays in diagnosis and treatment of patients with skin cancer: presentational delay of patients to the physician, diagnostic referral delay due to restrictions of diagnostic capacities, and/or treatment delay (decision to defer treatment due to increased risk of COVID‐19 transmission or health policy restrictions to treatment capacities).

A significant decrease in skin cancer diagnoses during the lockdown months in 2020 has been reported in studies from the UK Northern Cancer Network, ¹ and in US dermatology practices. ² A decrease in skin cancer referrals during the lockdown was reported in a study in the National Cancer Control Program in Ireland. ³ In a survey conducted by the Global Coalition for Melanoma Patient Advocacy, dermatologists across 36 countries estimated that one‐fifth (21%) of melanoma cases went undiagnosed and that one‐third of skin check appointments were missed due to the pandemic. ⁴

Furthermore, there are concerns that diagnostic delay may be associated with thicker and higher stage skin tumours. Retrospective single‐centre studies in a small number of patients have reported conflicting results on the Breslow thickness of melanomas diagnosed before and after COVID‐19 lockdown, with some studies reporting an increase in thickness ⁵ and others, a decrease. ⁶ A Spanish modelling study based on the rate of growth of melanomas predicted that with a 1‐month diagnostic delay, there would be an upstaging rate of 21%, while with a 3‐mongh diagnostic delay, there would be an upstaging in 45% of cases. ⁷ In another modelling study, for patients with invasive cutaneous melanoma in England, UK, a 3‐month delay to diagnosis was predicted to result in a reduction in long‐term 10‐year cancer‐specific net survival ranging from 3.13% in patients 30–39 years old, to 7.32% in patients 70–79, and 12.56% in patients of 80+ age. ⁸

Published recommendations on screening for skin cancer during the COVID‐19 pandemic are presented in Table 1. ⁹ , ¹⁰ It has been proposed that in order for skin cancer screening to be cost‐effective, high‐risk individuals should be targeted. This is even more so during the COVID‐19 pandemic. In the pre‐COVID era, it was reported that even patients diagnosed with melanoma did not perform skin self‐examination (SSE) on a regular basis. ¹¹ During the COVID‐19 pandemic, more patients may be inclined to perform SSE and to have fewer follow‐up clinic visits. In addition, primary care physicians may assist in skin cancer screening during the COVID‐10 pandemic to prevent visits to the hospitals after education on whole‐body skin examination, on mnemonic signs such as the ABCDE rule and the ‘ugly duckling’ sign and possibly on the use of dermoscopy.

Table 1.

Recommendations on screening for skin cancer during the COVID‐19 pandemic

	Screening for skin cancer in individuals with no prior history of skin cancer	Screening for skin cancer in patients diagnosed with melanoma
EADV Melanoma Task Force position statement 9	May be postponed for max 2–3 months: Periodical examinations due to increased melanoma risk	May be postponed for max 2–3 months: In COVID‐19 lockdown, follow‐up visits and imaging may be postponed in asymptomatic patients with stage 0‐IIA
	The use of teledermatology is recommended for routine check‐ups	Tumour‐free, high‐risk patients should continue to have physical and imaging exams, especially during the first 3 years after surgery of the primary tumour
		All patients should be educated and encouraged to perform skin self‐examination once per month
Belgian Association of Dermato‐Oncology position paper 10	Urgent care. No postponement: ‐ Referral for possible skin cancer ‐ Planned digital dermoscopy follow‐up of specific lesion(s) after 3–4 months	Urgent care. No postponement: ‐ Referral for possible skin cancer ‐ Planned digital dermoscopy follow‐up of specific lesion(s) after 3–4 months ‐ Follow‐up of stage II and stage III melanoma within first 2 years of follow‐up ‐ Follow up of multiple primary melanomas ‐ Follow‐up SCC of moderate/poor differentiation or prior metastasis or transplant patient or history of multiple SCCs ‐ Any patient with skin cancer history who is worried (first triage by teleconsultation)
	Semi‐urgent care. Can be postponed for max 8–12 weeks: ‐ Dysplastic nevus syndrome with family history of melanoma	Semi‐urgent care. Can be postponed for max 8–12 weeks: ‐ Follow‐up of stage II and stage III melanoma after 2 years of follow‐up ‐ Follow‐up stage I melanoma and in situ melanoma ‐ Follow‐up low‐risk SCC ‐ Follow‐up multiple BCC
	Low priority. Can be postponed beyond 12 weeks: ‐ Dysplastic nevus syndrome with negative personal/family history of melanoma	Low priority. Can be postponed beyond 12 weeks: ‐ Follow‐up BCC

Teleconsultation is advised whenever possible. ⁹ , ¹⁰ Teledermatology may be used for the triage of individual concerning lesions, and for virtual melanoma checks, especially for those at highest risk of SARS‐Cov‐2 infection including frail or elderly patients, and those with chronic diseases or immunosuppression. ¹² Teledermatology cannot replace medical inspection, dermoscopy and physical examination. However, teledermatology can help identify those patients who should present in person for an examination. In our experience, this is necessary in approximately one‐third of patients. Among proactive measures to raise awareness on skin cancer screening and diagnosis during the pandemic, TV spots and social media may bring tangible and user‐friendly messages to the public.

In conclusion, we have entered a phase of delayed care in the diagnosis and treatment of skin cancer patients due to the Covid‐19 pandemic. The actual impact of the pandemic on staging, survival and mortality will continue to be assessed as further empirical evidence accumulates. Once the pandemic is reasonably under control, we should undertake multifaceted efforts to care for those patients who have not been diagnosed or treated.