Dear Sir,The first confirmed cases of SARS-CoV-2 cornovirus disease (COVID-19) in the UK were on 29th January 2020. On 23rd March, a UK-wide “stay at home” lockdown period commenced, restricting freedom of movement in an effort to mitigate viral spread and protect NHS resources. At the time of writing, the UK has had over 300,000 confirmed cases of COVID-19 with a death toll of over 43,000 people. Many NHS hospitals across the UK are in various stages of lockdown as resources are redirected to the frontline.Anticipating complete redeployment of our department and the inability to operate, we acted early to prioritise urgent skin cancer cases to ensure they were done. We combined all consultant waiting lists to make sure patients were treated in the most timely manner, prioritising Malignant Melanoma (MM) and Squamous Cell Carcinoma (SCC). Our main theatre and peripheral hospital theatre lists were cancelled but we were able to streamline patients through our Plastic Surgical Treatment Centre (PSTC). This opened in September 2019 as a solution to our growing daycase skin cancerpatient waiting list. It comprises two operating theatres, a waiting reception area and a recovery bay.Interestingly, during this global pandemic, skin cancer referrals from General Practice and dermatology have reduced as presumably patients were not prepared to present for treatment. Unfortunately, some referrals that were eventually received were of more advanced disease. A proportion are on immunosuppressants or have significant co-morbidities, already shielding in the community, and have been reluctant to attend any skin cancers services based within hospitals.We designed consultant-led virtual clinics for new “urgent suspected cancer” (USC) patients. These patients were asked to submit photogaphs of their lesions to be available for the plastic surgeon when called. This meant patients were consulted very soon after their USC referral was received, often on the same day, and allowed informed discussion and booking of operations all without them having to leave their homes. We encourage all means of communication for prompt sharing of information during this time, including commercial mobile applications and personal email where there is no practical alternative. This is fully endorsed by NHS Digital, the National Data Guardian and the Information Commissioner's Office. Depending on the diagnosis, patients booked for PSTC would have a clinical examination of their lymph node basins on presentation for surgery.Patients must arrive to the PSTC at a designated time, alone, wearing appropriate Personal Protective Equipment (PPE) – typically a surgical face mask. They are pre-warned about COVID-19 symptoms beforehand and instructed to call and cancel should any develop. All surgical patients are treated as COVID-19 positive. Any potentially aerosilising procedures or surgeries on the head and neck require full PPE as advised by Public Health England. In fact, to protect patients and staff members, we avoided harvesting split-thickness skin grafts using powered dermatomes, an aerosol generating procedure (AGP), and opted for full-thickness skin grafting or local flaps where direct closure was not possible. The minimum number of staff are present inside the PSTC for it to run safely and efficiently. It is located close to an entrance at the rear of the hospital avoiding high footfall within main corridors. There are two morning and afternoon operating lists in two separate treatment rooms, typically allowing between 10–14 cases to be completed each working day. Patients can be kept 2 metres apart and the morning patients are discharged before the afternoon patients arrive. Postoperatively prior to discharge, patients are taught how to remove their own dressings (where absorbable sutures were used) or instructed to see their local GP practice nurse for suture removal and wound care to reduce returns to hospital. A small number of patients still need to attend our Plastic Surgery Dressing Clinic. When histology is available, consultants would write letters to patients and arrange appropriate follow up virtually, either by telephone or video platform.In January and February this year prior to the COVID-19 lockdown, we performed 371 surgical procedures for skin cancers under local anaesthetic comprising 204 BCCs, 116 SCCs and 51 MMs. The average waiting times from referral to operation were 138, 51, and 53 days respectively. In March and April, during the peak of the COVID-19 pandemic, we still managed to perform 268 surgical procedures for skin cancers under local anaesthetic through our PSTC service. This comprised 86 urgent BCCs, 100 SCCs and 82 MMs with average waiting times from referral to operation reducing to 95, 39, and 40 days respectively (Figures 1 and 2
). We successfully achieved a 72% caseload during the peak COVID months of March and April with respect to the previous January and February case totals; and there was a 28% overall reduction in mean average waiting times from receipt of referral to date of operation. Traumapatients were also treated through the PSTC when it was available to avoid any theatre slots going unfilled.
Figure 1
Number of skin cancer operations performed during pre-COVID (1st January – 29th February 2020) and peak COVID (1st March – 30th April 2020).
Figure 2
Mean average waiting time (in days) between receipt of urgent skin cancer referral and operation date during pre-COVID (1st January – 29th February 2020) and peak COVID (1st March – 30th April 2020).
Number of skin cancer operations performed during pre-COVID (1st January – 29th February 2020) and peak COVID (1st March – 30th April 2020).Mean average waiting time (in days) between receipt of urgent skin cancer referral and operation date during pre-COVID (1st January – 29th February 2020) and peak COVID (1st March – 30th April 2020).Whilst we are seeing falling numbers of newly diagnosed urgent skin cancer referrals as anticipated, telemedicine consultation and utilisation of an independent treatment centre for skin cancer surgery has improved service efficiency and the care we deliver to our patients. These adaptations, together with the practical steps in theatre management and minimising footfall, have allowed us to successfully continue working in a COVID-19 world. These are lessons we hope to take forward for the future delivery of our cancer services in the post-COVID era.
Figure 1
Figure 2