Characterising non-melanoma skin cancer undergoing surgical management during the COVID-19 pandemic.

Dear Sir,

Throughout the COVID-19 pandemic, plastic surgery departments have strived to keep oncological services running despite significant operational pressures. Access to healthcare generally declined in all but the most urgent circumstances, and departments have already identified a reduction in referrals and diagnoses of skin malignancies.

We investigated differences in patients presenting to our service for excision of non-melanoma skin cancer (NMSC) during the height of COVID-19 restrictions, in comparison to those presenting at the same time in 2019. We undertook a retrospective, single-centre case control study comparing 102 patients undergoing operative treatment for NMSC during the COVID-19 pandemic in 2020 to results from 127 patients undergoing treatment for NMSC in the same period in 2019. Data was collected from electronic operating lists and the electronic patient record. Dichotomous data was compared using Chi-squared tests and contiguous data using unpaired t-tests. A p-value of <0.05 was taken to be statistically significant.

Cases and controls were well matched in terms of patient demographics, lesion location, and operator training grade. Results are summarised in Table 1 . We identified a significant increase in the number of squamous cell carcinomas (SCC) excised relative to those excised in 2019, and a significant decrease in the number of basal cell carcinomas (BCC). Tumours removed in 2020 were significantly larger (14.8 mm vs 11.4 mm, p < 0.01). These larger lesions required more complex reconstruction (i.e. skin flap or graft), with fewer lesions amenable to direct closure (55.9% vs 67.6%, p = 0.04). The overall incidence of incomplete excision rates was higher in 2020 than in 2019, although this did not reach statistical significance (15% vs 7%, p = 0.06).

Table 1

Summary of results. **indicates a statistically significant difference.

	2019 (n (lesions) = 127)	2020 (n (lesions) = 102)	p =
Age (Mean (SD))	75.67 (11.35)	74.6 (12.17)	0.17
Sex (n)			–
Males	56	54
Females	36	36
Pre-op Diagnosis (n)			0.03**
BCC	86	51
SCC	37	48
Other	2	3
Mean time to procedure – All lesions (days)	109	115	0.77
Mean time to procedure – Suspected SCC (days)	43.7	41.9	0.84
Body Site (%)			0.20
Head & Neck	75.8	85.3
Trunk	11.7	6.9
Upper Limb	4.7	1.0
Lower Limb	7.8	6.9
Head and Neck Subtype (%)			0.43
Scalp	8.2	17.2
Peri-ocular, temple, forehead, eyebrow	41.2	36.8
Cheek/Chin	19.6	18.4
Ear	9.3	12.6
Nose or Lips	17.5	12.6
Neck	4.1	2.3
Senior Operator Grade (%)			0.57
Consultant	47.1	43.1
specialty Registrar	47.9	53.9
Senior house officer/Core Trainee	5.0	2.9
Histological Diagnosis (n)			<0.01**
BCC	67	37
SCC	16	30
Actinic Keratosis	14	14
Bowen's Disease	3	2
Benign	23	14
Other	1	5
Largest Tumour diameter in mm (mean (SD))	11.4 (7.8)	14.8 (9.8)	<0.01**
Reconstruction (%)			0.04**
Direct Closure	67.7	55.9
SSG	5.5	13.7
FTSG	14.1	13.7
Local Flap	11.7	7.8
Incomplete – All lesions (%)	7.0	15.7	0.06
Incomplete – BCC (%)	9.0	21.6	0.07
Incomplete – SCC (%)	6.3	13.3	0.46

In our study, we found no difference in the time from initial referral to definitive treatment between groups. This provides reassurance that although under operational pressure, with staff redeployed and operating theatres closed, the service continued to treat malignancy in a timely manner.

Our findings show that throughout the height of the COVID-19 pandemic our department saw significantly larger NMSC lesions, with a higher proportion of these being SCCs that required more complex reconstruction following excision. Reasons for this are likely to be multi-factorial. It is documented that patients have had delayed presentation to healthcare services throughout the pandemic. Reduction in face-to-face appointments in primary care and potential hesitancy in the use of usual referral pathways to secondary care may also play a part.

The increase in incomplete excision rate seen in 2020 is clinically significant, and higher than an estimated 10% global rate found in a systematic review in press. Larger, more invasive lesions may be likely to result in an increase in incomplete excision margins. Timely diagnosis of these NMSC lesions and treatment with clear margins is important, as 31–41% of lesions without clear margins will recur. An increase in patients with incomplete excision margins will often lead to further surgical intervention and ultimately an increase in patient morbidity. In our study, since patients were well matched demographically and in terms of seniority of surgeon, this increase was likely to be related to lesion factors rather than surgical factors, or an as yet unexplored confounding factor.

Despite prioritisation of oncological services throughout the pandemic thus far, our findings show substantial differences in the patients accessing skin oncology services in our centre. It appears that current delays to definitive surgical treatment of smaller, less aggressive BCCs may mean patients are missing the opportunity to benefit from early excision of these lesions. There is a risk that should this trend continue, a large cohort of patients with these ostensibly less aggressive tumours may experience a delay in their treatment, requiring yet more complex reconstructive surgery as seen in this study. Further work is needed to streamline referral pathways and maintain access to services for patients, in the increasingly likely event of restrictions on elective services due to a second wave.

Declaration of Competing Interest

N/A.