Communication: A safe skin cancer surgery set-up during the COVID-19 crisis.

Dear Sir,

After its emergence in December 2019, the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 or COVID-19) has resulted in a global pandemic. Transmission of the virus is thought to be mainly airborne during close human-to-human contact. The average incubation period has been reported to be between 3.0 and 6.4 days. Asymptomatic disease may represent a large number of cases, which with pre-symptomatic transmission, may explain the rapid spread of this infection. ,

Redirection of healthcare resources required to deal with the COVID-19 pandemic inadvertently paralysed the delivery of the majority of surgical care. Especially regarding oncological surgery, one must consider the collateral damage that will follow if time-critical procedures are delayed or aborted. The morbidity and mortality resulting from the COVID-19 pandemic, is not only a result from the disease itself, but includes those whose prognosis may have been affected by not receiving timely care.

By initiating dedicated local anaesthetic skin cancer operating lists in an affiliated private hospital, our tertiary plastic surgery unit provided continuation of care for this patient population throughout the pandemic. This correspondence presents the set-up and successful precautions taken to prevent transmission of the Coronavirus between patients and healthcare workers.

Between March 24th and April 14th 2020, fifty patients underwent surgery under local anaesthetics for localised skin cancer. Admission staff screened everyone for signs of COVID-19. Crowding was avoided by staggered admission times and only allowing patients into the hospital. On arrival for surgery, the patients’ temperature was checked and they were placed into a separate bay or room. During the admission and consent process healthcare workers would distance from the patient as much as possible, whilst using basic personal protective equipment (PPE - surgical mask, protective visor and gloves). Patients were also offered a mask to wear throughout the surgical procedure, unless this interfered with field sterility. Staffing levels in the operating theatre consisted of 1 or 2 surgeons, a scrub nurse and 1 or 2 runners. All present healthcare personnel wore a mask (FFP3 or normal surgical mask, hat and visor, whilst in addition the surgeons and scrub nurse were fully gowned as per normal for a sterile procedure.

Care was taken to choose surgical options minimising the need for further hospital visits. Telephone follow-up by a Plastic Dressing Clinic nurse was arranged the week after surgery, and the histopathology result and further plan conveyed by a medical member of the Plastic Surgery department, after discussion in our virtual skin multidisciplinary team (MDT) meeting.

All fifty patients were contacted by telephone to evaluate if they had developed COVID-19 symptoms, as per questionnaire in Figure 1 . Their procedure had been a minimum of 3 weeks earlier, thereby having completed the maximum incubation period of 2 weeks at the time of evaluation.

Figure 1

Questions used in skin cancer surgery and COVID-19 evaluation.

The average age of the patients was 62 years, with a preponderance of males (56%). The most common malignancy excised was melanoma (58%), with Basal and Squamous Cell carcinomas representing almost equal shares of the remaining operations. The most common area treated was the head and neck (42%), followed by the torso (26%), lower limb (18%) and the upper limb (14%) (Table 1 ).

Table 1

Patient and tumour characteristics.

Mean Age (±SD)	62 years (±13.5)
Male Sex	n = 28	56%
Type of Skin Cancer	Melanoma n = 29	58%
	SCC n = 10	20%
	BCC n = 9	18%
	Melanoma in situ n = 2	4%
Treated Area	Head and Neck n = 21	42%
	Torso n = 13	26%
	Lower Limb n = 9	18%
	Upper Limb n = 7	14%
Vulnerable Patients	n = 19	38%

SD = Standard Deviation.

SCC = Squamous Cell Carcinoma; BCC = Basal Cell Carcinoma.

None of the contacted fifty patients developed any symptoms of COVID-19 in the 3–6 weeks following their surgical procedure. It speaks to the efficiency of PPE and physical distancing that we did not detect any evidence of COVID-19 transmission.

The guideline published by NHS in April 2020, advises Plastic Surgery services to continue to offer surgical treatment within one month for the following skin cancers: melanoma; poorly differentiated tumours; nodal disease; compromise of vital structures, including the eye, nose and ear. In line with above national guidelines, over half of patients treated in the reviewed three-week period had melanoma and 42% of tumours were located in the head and neck region.

Asymptomatic and pre-symptomatic healthcare workers are an under-appreciated potential source of infection, to both co-workers and patients. Over the last month, the UK government has expanded testing capacity, but currently still only symptomatic health care workers are offered testing. Availability of screening tests for staff would be a desirable adjunct to our current measures to reduce disease transmission. Continuing to use COVID-free locations for elective surgery other than the primary NHS hospitals, is likely to be important going forward as we expect COVID-19 will continue to affect life for the considerable future. The results of this communication can be used when discussing the oncological risk of delaying surgery vs the COVID-19 transmission risk for patients undergoing a procedure under local anaesthesia.

By putting all of the above safety measures in place, we believe we can provide a safe environment where patients and staff can feel confident in proceeding with elective surgery under local anaesthesia.

Declaration of Competing Interest

The authors have no conflict of interest to declare.