Management of patients with melanoma and non – melanoma skin cancers in the coronavirus disease 2019 era

0
0
0

Management of patients with melanoma and non-melanoma skin cancers in the coronavirus disease 2019 era

Since the COVID-19 pandemic began, hospitals and clinics worldwide have restructured care to focus on emergencies—and dermatology is no exception. For patients with skin cancers like melanoma or non-melanoma skin cancers (NMSCs), this has meant delays, new safety protocols, and a rapid shift to virtual care.

Early diagnosis is non-negotiable for skin cancer survival. For melanoma, catching it at stage 0 or 1 (when it’s still localized) means a 99% 5-year survival rate. But COVID-19 has forced many routine dermatology visits to pause, raising fears that missed or delayed diagnoses could let cancers progress to more dangerous stages. This is a critical concern: studies suggest pandemic-related care delays could lead to tens of thousands of excess cancer deaths globally.

Teledermatology: A Lifeline for Early Triage

Teledermatology—using video calls, secure image sharing, or videodermatoscopy—has become essential to bridge the gap. It lets doctors evaluate suspicious lesions (like a new mole, scaly patch, or growing bump) without patients entering clinics, reducing COVID-19 risk while preventing cancer progression.

For example:

  • A patient with an atypical mole can send high-quality photos to their dermatologist, who uses the ABCDE rule (Asymmetry, Border, Color, Diameter, Evolution) to decide if an in-person visit is urgent.
  • Videodermatoscopy—which uses a camera to magnify skin lesions by 10–100x—lets doctors examine spots closely while keeping a safe distance. This is especially useful for facial lesions (e.g., on the eyelid or lip), where close contact was once necessary.

Teledermatology also helps with follow-ups: melanoma survivors or patients on topical treatments can check in via phone or video, ensuring they stay on track without exposure risk.

Treatment Shifts to Protect High-Risk Patients

Older adults are most likely to have actinic keratoses (AKs)—precancerous sun spots that can turn into squamous cell carcinoma (SCC)—and they’re also at highest risk for severe COVID-19. At our clinic, we typically treat 900 patients yearly with photodynamic therapy (PDT) for AKs, Bowen disease, or superficial basal cell carcinomas (BCCs). But during the pandemic, we’ve paused most PDT treatments. Instead, we use topical creams (like 5-fluorouracil or imiquimod) for select patients, with virtual follow-ups to monitor progress.

For surgeries, we prioritize high-risk cases:

  • Invasive melanoma (wide re-excisions are done immediately).
  • Fast-growing SCCs or BCCs on “high-risk H-areas” of the face (eyelids, lips, eyes).
  • Suspected melanoma in situ (excised with 5mm margins right away).

Low-risk cancers (e.g., small BCCs <0.5cm) are postponed—unless they’re growing or changing. When surgery can’t wait, we:

  1. Space appointments to avoid crowded waiting rooms.
  2. Require patients to wear masks the entire time in the clinic.
  3. Test for COVID-19 before major procedures (e.g., those needing hospitalization or frequent wound checks).
  4. Switch to topical treatments when possible (e.g., using cream for a low-risk BCC instead of surgery).

Systemic Therapies: Caution and Personalization

For patients on systemic treatments (like immunotherapy or targeted therapy), never stop without consulting your doctor—even if you have flu-like symptoms. For new patients, we prefer oral targeted therapies (e.g., BRAF/MEK inhibitors for melanoma) over immunotherapy: immunotherapy can cause side effects (like pneumonia or colitis) that mimic COVID-19, making it hard to diagnose infections early.

We also test patients for COVID-19 before starting any systemic treatment. If a patient tests positive or has symptoms (e.g., shortness of breath), we may pause treatment for 2–6 weeks until they recover—following guidelines from the Italian Association of Medical Oncology (AIOM) and European Society of Medical Oncology (ESMO).

Advanced BCCs: Hedgehog Inhibitors Remain a Safe Option

For locally advanced BCCs, drugs that target the Hedgehog pathway (vismodegib and sonidegib) are still recommended. Their side effects—like muscle pain or hair loss—don’t overlap with COVID-19 symptoms, so they’re easier to manage. We track progress with teledermatology: patients send high-resolution photos of their lesions, and we adjust doses (or pause treatment temporarily) if side effects arise.

The Biggest Challenge: Keeping Patients Engaged in Follow-Up

Melanoma survivors need regular check-ins to catch recurrence early. We proactively reach out via phone or email to remind patients of appointments and teach them to self-examine using the ABCDE rule. For metastatic melanoma patients on treatment, virtual check-ins help them stay compliant and address side effects without in-person visits.

Balancing Safety and Urgency

The pandemic has upended skin cancer care—but it hasn’t weakened our commitment to early diagnosis and safe treatment. Teledermatology, careful prioritization of cases, and clear communication are helping us protect patients while addressing the urgency of skin cancer.

If you have a suspicious lesion, are on skin cancer treatment, or are due for a follow-up: don’t wait. Reach out to your dermatologist. Early action saves lives—even during a pandemic.

By Claudio Conforti, MD; Nicola di Meo, MD; Roberta Giuffrida, MD; and Iris Zalaudek, MD
Dermatologists at the University of Trieste (Italy) and University of Messina (Italy)

References

  1. Conforti C, Cannavò SP, Jafferany M, et al. Coronavirus disease 2019 (COVID-19): facts and controversies. Dermatol Ther 2020;e13366. doi: doi.org/10.1111/dth.13366
  2. Conforti C, Giuffrida R, Dianzani C, et al. COVID-19 and psoriasis: Is it time to limit treatment with immunosuppressants? A call for action. Dermatol Ther 2020. doi: doi.org/10.1111/dth.13298
  3. Schrag D, Hershman DL, Basch E. Oncology practice during the COVID-19 pandemic. JAMA 2020. doi: doi.org/10.1001/jama.2020.6236
  4. Conforti C, Beninati E, Dianzani C. Are actinic keratoses really squamous cell cancer? How do we know if they would become malignant? Clin Dermatol 2018;36:430–432. doi: doi.org/10.1016/j.clindermatol.2017.08.013
  5. Conforti C, Paolini F, Venuti A, et al. The detection rate of human papillomavirus in well-differentiated squamous cell carcinoma and keratoacanthoma: is there new evidence for a viral pathogenesis of keratoacanthoma? Br J Dermatol 2019;181:1309–1311. doi: doi.org/10.1111/bjd.18212
  6. Puig S, Berrocal A. Management of high-risk and advanced basal cell carcinoma. Clin Transl Oncol 2015;17:497–503. doi: doi.org/10.1007/s12094-014-1272-9
  7. Woltsche N, Pichler N, Wolf I, et al. Managing adverse effects by dose reduction during routine treatment of locally advanced basal cell carcinoma with the hedgehog inhibitor vismodegib: a single centre experience. J Eur Acad Dermatol Venereol 2019;33:e144–e145. doi: doi.org/10.1111/jdv.15367
  8. Villani A, Fabbrocini G, Costa C, et al. Patients with advanced basal cell carcinomas in treatment with sonic hedgehog inhibitors during the coronavirus disease 2019 (COVID-19) period: management and adherence to treatment. J Am Acad Dermatol 2020. doi: doi.org/10.1016/j.jaad.2020.03.057
  9. Conforti C, Giuffrida R, Di Meo N, et al. Management of advanced melanoma in the COVID-19 era. Dermatol Ther 2020. doi: doi.org/10.1111/dth.13444
  10. AIOM. Rischio infettivo da Coronavirus Covid-19: indicazioni per l’oncologia. Available from: https://www.aiom.it/wp-content/uploads/2020/03/20200313_COVID-19_indicazioni_AIOM-CIPOMO-COMU.pdf
  11. ESMO. Cancer patient management during the covid-19 pandemic. Available from: https://www.esmo.org/guidelines/cancer-patient-management-during-the-covid-19-pandemic?hit=ehp

Was this helpful?

0 / 0