Dear Sir,
Introduction
The SARS-CoV-2 pandemic has had a substantial impact on the provision of surgical services worldwide.1 In the United Kingdom, staff redeployment and reduced staffing due to infection and self-isolation has reduced the availability of clinic slots and theatre lists. Additionally, there has been a substantial reduction in the volume of patients presenting to general practice and hospitals during the height of the pandemic.1 The potential compounded effects of a reduction in referrals along skin cancer pathways and availability of specialist review and intervention has placed patients at risk of delayed investigation, diagnosis, and treatment, and incurred a possibility of adverse outcomes and an increase in morbidity and mortality.2 , 3 The aim of this study was to assess the impact of the pandemic upon patients presenting to a speciality skin cancer service.
Methods
This was a single-centre retrospective matched cohort study. All patients diagnosed with cutaneous melanoma or squamous cell carcinoma between April and October 2020 were included and compared to those diagnosed in the same time frame in 2019. Disease specific outcomes included Breslow thickness, Clark's level, pT and TNM staging at presentation. Service outcomes included referral source and time to referral, diagnosis, and treatment. Data analysis techniques are described in supplement 1.
Results
Malignant melanoma (MM)
There was a 32.1% overall reduction in MM diagnoses in 2020 compared to 2019 (74 vs 109). A summary of results is shown in Table 1 .
Table 1.
Cutaneous melanoma results summary.
| Demographic | 2019 (n = 109) | 2020 (n = 74) | p = |
|---|---|---|---|
| Age (±SD) | 64.3 (±16.5) | 63.5 (±17.0) | 0.769 |
| Gender | |||
| Female (%) | 60 (55%) | 42 (57%) | 0.819 |
| Male (%) | 49 (45%) | 32 (43%) | |
| Location (%) | |||
| Head and Neck | 20 (18.7%) | 12 (16.2%) | 0.850 |
| Upper Limb | 28 (26.2%) | 18 (24.3%) | |
| Lower Limb | 31 (29%) | 26 (35.1%) | |
| Trunk | 18 (26.2%) | 18 (24.3%) | |
| Stage | |||
| T Stage (%) | |||
| T1 | 52 (49.1%) | 33 (44.6%) | 0.381 |
| T2 | 26 (24.4%) | 13 (17.6%) | |
| T3 | 10 (9.4%) | 9 (12.2%) | |
| T4 | 18 (17.0%) | 19 (25.7%) | |
| N Stage (%) | |||
| N0 | 94 (88.7%) | 59 (79.7%) | 0.098 |
| N1 | 8 (7.5%) | 10 (13.5%) | |
| N2 | 3 (2.8%) | 3 (4.1%) | |
| N3 | 1 (0.9%) | 2 (2.7%) | |
| M Stage (%) | |||
| M0 | 104 (97.2%) | 72 (97.3%) | 0.967 |
| M1 | 3 (2.8%) | 2 (2.7%) | |
| PT Stage (%) | |||
| PT1a | 43 (39.4%) | 21 (28.4%) | 0.168 |
| PT1b | 9 (8.3%) | 12 (16.2%) | |
| PT2a | 24 (22.0%) | 10 (13.5%) | |
| PT2b | 2 (1.8%) | 3 (4.1%) | |
| PT3a | 6 (5.5%) | 4 (5.4%) | |
| PT3b | 4 (3.7%) | 5 (6.8%) | |
| PT4a | 4 (3.7%) | 6 (8.1%) | |
| PT4b | 14 (12.8%) | 13 (17.6%) | |
| Measurement | |||
| Lesion Diameter (mm) – Mean (±SD) | 13.33 (± 8.88) | 13.35 (±8.44) | 0.952 |
| Breslow Thickness (mm) – Mean (±SD) | 2.3 (±4.1) | 3.1 (±3.7) | 0.205 |
| Clark's Level (%) | |||
| I | 0 (0%) | 0 (0%) | <0.01 |
| II | 12 (12.2%) | 0 (0%) | |
| III | 24 (24.5%) | 22 (31.0%) | |
| IV | 57 (58.2%) | 39 (54.9%) | |
| V | 5 (5.1%) | 10 (14.1%) |
Time from referral to clinic review was not significantly different between the two cohorts. Time from clinic review to biopsy was significantly shorter in 2020 (17.4 days vs 27.1 days, p = 0.03), as was time from MDT discussion to subsequent treatment (35.2 days vs 47.3 days, p<0.01). Breslow thickness, TNM and pT staging trended towards an increase in 2020, however none of these achieved statistical significance. There was a significant increase in Clark's level in 2020 (p < 0.01).
Squamous cell carcinoma (SCC)
There was an overall reduction in SCC diagnoses of 27.7% in 2020 (198 vs 274). A summary of results is shown in Table 2 .
Table 2.
Squamous cell carcinoma results summary.
| Demographic | 2019 (n = 274) | 2020 (n = 198) | P = |
|---|---|---|---|
| Age (±SD) | 80.0 (±9.9) | 78.8 (±11.2) | 0.234 |
| Gender Female (%) Male (%) |
78 (28%) 204 (72%) |
61 (30%) 139 (70%) |
0.498 |
| Stage (%) | |||
| T1 T2 T3 T4 |
112 (40.9%) 154 (56.2%) 8 (2.9%) 0 |
137 (69.2%) 31 (15.7%) 30 (15.2%) 0 |
<0.001 |
| N0 N1 N2 |
274 (100%) 0 0 |
195 (98%) 3 (1.5%) 1 (0.5%) |
0.026 |
| M0 M1 |
274 (100%) 0 |
195 (98%) 4 (2%) |
0.03 |
| Measurement | |||
| Lesion Diameter (mm) – Mean (±SD) | 17.37 (± 11.42) | 16.49 (±10.33) | 0.413 |
| Complete Excision (%) | 95.8% | 94.4% | 0.924 |
Time from referral to clinic review was equivocal. There was no significant difference in time from clinic to first procedure (37.29 days vs 35.09 days, p = 0.562). Time from procedure to MDT discussion was significantly shorter in 2020 (21.60 days vs 26.50 days, p<0.0001). There was a significant increase in MDT recommendations for further treatment in 2020 (19.5% vs 16.0%, p = 0.034). There was a significant increase in tumour, nodal, and metastatic stage at presentation in 2020 when compared to 2019.
In 2020, the proportion of diagnoses originating from primary care was significantly increased (76.5% vs 67.4% p = 0.049) and new lesions identified during secondary care follow up decreased (18.0% vs 27.7%). Routine GP referrals were similar across both groups (5.5% vs 5%).
Discussion
The findings of this study demonstrate both successes and concerns in the management of skin cancer during the pandemic. Evidence demonstrates that clinic wait times have reached record levels,4 and while the initial expectation is that this would slow progression through the cancer care pathway, this study demonstrates evidence to the contrary. During the pandemic there was no increase in time between GP referral and specialist clinic review for patients with suspected skin cancer, and once within the hospital pathway patients received accelerated care. This may be due to an increased focus on higher risk cancers. A reduction in histological samples due to reduced theatre workload may have also reduced the wait time for samples to be analysed, thus decreasing time between surgery and MDT. Additionally, the implementation of “hot” clinics with same day excisions likely further reduced wait times.
Fewer patients were seen overall in the 2020 cohort, potentially reducing the strain on the service, and shortening wait times. This is reflected by a reduction in GP fast track referrals during the pandemic, estimated to be as high as 60% nationally,5 with a more modest reduction of 19.5% seen in this study. A reduction in primary care referrals suggests the existence of a cohort of patients who have not yet presented to general practice.
This study found a 53.8% reduction in new lesions diagnosed through secondary care follow up. A significant reduction in SCCs identified during follow up appointments demonstrates a possible explanation for part of this missing cohort of patients, with ‘routine’ follow-up cancellations likely leading to missed diagnoses. This same effect was not seen with MM, which may be due to clinical prioritisation, a younger cohort and lower risk of second primary lesions.
This study shows some evidence that patients are presenting at a later stage of disease. MMs demonstrated an increased Clark's level during the pandemic, with Breslow thickness trending towards an increase. The trend in SCC is more concerning, with significant increases in tumour, nodal, and metastatic stage at presentation. Treatment of metastatic SCC can involve additional surgery, oncology input, and frequent follow up. This, combined with the aforementioned missing cohort of patients, means that the impact of COVID19 on skin cancer services is ongoing, as once standard practice is restored, the service is likely to be faced with an increased patient load, requiring more invasive, time-consuming and costly treatment. We therefore suggest that it would be valuable to continue multi-centre prospective data collection to assist in resource planning.
Ethical approval
Approval for retrospective data collection obtained via local audit department
Funding
None
Declaration of Competing Interest
None
Footnotes
Data presented in part at the 10th World Congress of Melanoma 15th-17th April 2021
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.bjps.2022.06.062.
Appendix. Supplementary materials
References
- 1.Collaborative C. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440–1449. doi: 10.1002/bjs.11746. [published Online First: 20200613] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Capitelli-McMahon H., Hurley A., Pinder R., et al. Characterising non-melanoma skin cancer undergoing surgical management during the COVID-19 pandemic. J Plast, Reconstruct Aesthet Surg. 2020 doi: 10.1016/j.bjps.2020.10.042. [published Online First: 31 Oct 2020] [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Nolan G.S., Dunne J.A., Kiely A.L., et al. 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. BJS (Br J Surg) 2020 doi: 10.1002/bjs.12047. n/a(n/a) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Griffin S. Covid-19: waiting times in England reach record highs. Bmj. 2020;370:m3557. doi: 10.1136/bmj.m3557. [published Online First: 20200911] [DOI] [PubMed] [Google Scholar]
- 5.Mahase E. Covid-19: urgent cancer referrals fall by 60%, showing "brutal" impact of pandemic. Bmj. 2020;369:m2386. doi: 10.1136/bmj.m2386. [published Online First: 20200612] [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.