Struggling with COVID: Every cancer patient is unique and needs their own plan
Authors: Murad Alam
Journal: Journal of the American Academy of Dermatology (2020)

Geskin et al1Geskin L.J. Trager M.H. Aasi S.Z. et al.Perspectives on the recommendations for skin cancer management during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 83: 295-296Abstract Full Text Full Text PDF Scopus (18) Google Scholar suggest changes to skin cancer management in the context of COVID-19. Needless to say, the authors have thought carefully about this issue, and their suggestions are well-intentioned ideas for minimizing risk and improving patient welfare. Even so, there are limitations to this type of guidance. In particular, these recommendations are based more on opinion than evidence, and the underlying factual elements are subject to change:1.Circumstances and risks associated with COVID-19 are constantly changing and may differ by geographic region.2.The referenced National Comprehensive Cancer Network emergency guidance did not go through the formal National Comprehensive Cancer Network consensus process due to time sensitivity.3.These recommendations assume that we know how long to delay cancer treatment in normal times and that waiting longer is acceptable during the pandemic. In fact, we have little evidence regarding appropriate waiting times based on the natural history of individual cancers. Creating a reliable model to estimate the harm associated with waiting longer is challenging.4.Conserving resources, presumably personal protective equipment, is stated as a goal of these recommendations, but it is not clear what extent of shortage of personal protective equipment is envisioned. Each region of the country has differed widely in its ability to procure personal protective equipment, and availability may also change over time.5.The suggestion that the least complex reconstruction may be best is likely predicated on the assumption that this may be quicker and associated with fewer adverse events. Indeed, the principle of the reconstructive ladder always dictates simplicity over complexity. However, at times the patient may be better served by an alternative approach. In short, the recommendations offered by Geskin et al may be the right approach for a given patient, with a particular type of tumor, treated by a given doctor, under certain specific circumstances of the pandemic. But they are not generalizable. The authors are to be commended for using terms like "may," "propose," and "consider" to highlight the need for the treating physician to tailor the treatment plan for the individual patient. Every patient with skin cancer is unique. The pathologic diagnosis and stage of a tumor are insufficient to know what course may be right for an actual patient. Even under normal circumstances, our knowledge is limited, and the conditions of the pandemic are uncertain and evolving. What is certain is that many dermatologists, including Geskin et al,1Geskin L.J. Trager M.H. Aasi S.Z. et al.Perspectives on the recommendations for skin cancer management during the COVID-19 pandemic.J Am Acad Dermatol. 2020; 83: 295-296Abstract Full Text Full Text PDF Scopus (18) Google Scholar are working hard to provide the best care possible for our patients in these challenging times. General guidance can be helpful when it is followed by careful consideration of each clinical situation by a board-certified dermatologist who can work with the patient to create an individualized treatment plan. Regulators, government officials, payers, and administrators should defer to the treating physician, who is the only one with a duty of care and the medical expertise to do what is best for his or her patient. Perspectives on the recommendations for skin cancer management during the COVID-19 pandemicJournal of the American Academy of DermatologyVol. 83Issue 1PreviewThe National Comprehensive Cancer Network and American College of Mohs Surgery have released guidelines for managing cancer during the human severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. The detailed National Comprehensive Cancer Network and American College of Mohs Surgery recommendations are available online ( https://www.nccn.org/covid-19/default.aspx and https://www.mohscollege.org/ ), and here we provide our perspective.1 Full-Text PDF