Healthcare and safety of patients with melanoma during the COVID-19 Pandemic in Italy.

Conflicts of interest

No conflict of interest.

Funding sources

This work was partially supported by the Italian Ministry of Health with Ricerca Corrente 5 per 1000 funds.

Dear Editor,

The COVID‐19 pandemic prompted drastic containment measures and a rearrangement of healthcare services. Several papers highlighted the reduction of melanoma diagnoses and related activities , , , , ; however, limited data are available on healthcare quality and patient safety.

In Italy, the Italian Melanoma Intergroup (IMI) documented the decrease in first visits, diagnoses and surgeries related to melanoma during February–April 2020. As a follow‐up study, the IMI and the Italian Association of Melanoma Patients (AIMaMe) undertook a nationwide survey to evaluate the impact of the pandemic on healthcare quality and patient safety in melanoma management. AIMaMe members were invited to fill in an online questionnaire, and participants were divided into two groups based on when they received the indication for excision: pre‐pandemic (Group 1, n = 334) and pandemic (Group 2, n = 252; Table 1).

Table 1

Survey questionnaire

	The dermatological examination in which melanoma was diagnosed took place:
	From January 2019 to January 2020		From February 2020 to December 2020		p‐value†
Why did you undergo the dermatological examination in which melanoma was diagnosed?
Suspicious skin lesion	141	42.2%	110	43.7%
Regular nevus check‐up	150	44.9%	105	41.7%
Other reason	43	12.9%	37	14.7%	0.688
Who suggested to undergo a dermatological examination?
Myself	116	34.7%	90	35.7%
Dermatologist	119	35.6%	82	32.5%
Family member or friend	40	12.0%	33	13.1%
General practitioner	32	9.6%	25	9.9%
Other medical doctor	27	8.1%	22	8.7%	0.672
How long did you have to wait for an appointment for the dermatological examination?
<1 month	174	52.1%	151	60.0%
1–3 months	120	35.9%	61	24.2%
3–6 months	31	9.3%	20	7.9%
6–12 months	9	2.7%	20	7.9%	0.001
How long did you have to wait for the surgical removal of your melanoma?
<15 days	120	35.9%	107	42.5%
15–60 days	175	52.4%	127	50.4%
2–6 months	34	10.2%	15	6.0%
6–12 months	5	1.5%	3	1.2%	0.173
How long did you have to wait to receive the histological report after surgery?
<15 days	155	46.4%	130	51.6%
up to 1 month	137	41.0%	99	39.3%
>1 month	42	12.6%	23	9.1%	0.295
Did COVID‐19 restrictions cause a delay of …	… at least one follow‐up visit?		… the first follow‐up visit?
No	259	77.5%	187	85.0%
Yes, my decision	19	5.7%	11	5.0%
Yes, decision by the health facility management	56	16.8%	22	10.0%	0.069
If yes, how long was the visit delayed?
<1 month	8	10.7%	9	27.3%
1–3 months	34	45.3%	15	45.5%
3–6 months	15	20.0%	7	21.2%
>6 months	18	24.0%	2	6.1%	0.042
How afraid did you feel during medical encounters (for melanoma surgery or follow‐up visit) during the COVID‐19 pandemic?	4	(0–10)	4	(0–10)	0.665
Did you feel safe while undergoing melanoma surgery or follow‐up visits during the COVID‐19 pandemic?
Yes	283	84.7%	237	94.0%
No	51	15.3%	15	6.0%	<0.001
Overall, how do you rate the management of your melanoma during the COVID‐19 pandemic?
Excellent	152	45.5%	145	57.5%
Good	130	38.9%	85	33.7%
Fair	42	12.6%	14	5.6%
Poor or Bad	10	3.0%	8	3.2%	0.006
In your opinion, how did the management of melanoma change during the COVID‐19 pandemic compared to the pre‐pandemic era?
Unchanged	270	80.8%
Improved	20	6.0%
Worsened	44	13.2%

Chi‐square test for categorical variables, and rank sum test (comparing medians) for continuous variables.

Regarding patient management, we found no differences between the groups. The main reasons for the dermatology visit were a suspicious lesion (42–44%) and a routine clinical evaluation of nevi (42–45%). There were also no differences in who suggested the visit: the most frequent answers were ‘myself’ (35–36%) and ‘a dermatologist’ (36–32%). A waiting time <15 days was non‐significantly more frequent in Group 2 for surgical removal (42.5% vs. 35.9%) and histological report (51.6% vs. 46.4%). Moderate, yet significant, differences emerged regarding the wait time for the dermatologist appointment: in group 1, 88.0% of patients had to wait <3 months, and 2.7% >6 months, while in group 2, these percentages were 84.1% and 7.9%.

In terms of healthcare quality, Teuscher et al. and Raza et al. observed a 15–17% of postponed or cancelled appointments, mostly due to concern about COVID‐19. Furthermore, in Raza et al., lack of check‐ups or long waiting times were more frequent during lockdown than before (72% vs. 28%). We also observed a lower rate of patients reporting delayed follow‐up visits; but unexpectedly, among patients in group 2 (15% vs. 22.5% in group 1, 10% vs. 16.8% of which by decision of the health facilities).

Concerning perceived safety, the patients in the two groups did not differ in their fear of undergoing a procedure during the pandemic, and the percentage of patients who felt safe was even higher in group 2 (94.0% vs. 84.0%). This was consistent with Kurzhals et al., who observed that the pandemic did not substantially affect the overall quality of life of skin cancer patients. The percentage of patients who considered melanoma management to be good/excellent during the pandemic was also higher in Group 2 (91.2% vs. 84.4%). The significantly higher rates of satisfaction and perceived safety in group 2 could be due to the fact that some of these patients received the diagnosis after the end of the lockdown, when the healthcare facilities had already re‐organized their activities.

Finally, most group 1 patients (80.8%) stated that melanoma management was unchanged during the pandemic, while a smaller percentage reported a worsening (13.2%) or an improvement (6.0%).

A limitation of this study was that questionnaires were filled in only online. Patients less digitally competent, especially the elderly, may thus be under‐represented. Survey participants may also be more health‐conscious than non‐participants, thereby possibly creating a selection bias. Finally, teledermatology was not investigated in our survey due to ongoing clinical validation and medico‐legal restrictions.. ,

In conclusion, healthcare quality and patient safety appear to have been generally guaranteed in melanoma management during the COVID‐19 pandemic in Italy. Given the ongoing situation, additional multi‐centre studies are required to determine the long‐term impact of the pandemic on melanoma patients.