Impact of COVID-19 delays on skin cancer worry and Mohs micrographic surgery for keratinocytic carcinoma
Authors: Emily Stamell Ruiz, Inge J. Veldhuizen, Aleisa Abdullah, Anthony Rossi, Kishwer S. Nehal, Chrysalyne Schmults, Abigail Waldman, Erica H. Lee
Journal: Journal of the American Academy of Dermatology (2021)

To the Editor: In March 2020, the National Comprehensive Cancer Network recommended delaying treatment during the COVID-19 pandemic for keratinocyte carcinoma (KC), except for tumors determined to pose a risk of "metastasis or debilitating progression within 3 months."1National Comprehensive Cancer Network COVID-19 Resources: advisory statement for Non Melanoma Skin Cancer Care during the COVID-19 Pandemic.https://merkelcell.org/wp-content/uploads/2020/05/NCCN-NMSC.pdfDate: April 22, 2020Date accessed: September 17, 2021Google Scholar This study sought to evaluate the impact of the COVID-19 pandemic on cancer worry in patients undergoing Mohs micrographic surgery (MMS) for KCs. The study was approved by the institutional review boards of Brigham and Women's Micrographic Surgery Center and Memorial Sloan Kettering Cancer Center. KCs treated with MMS at both the institutions were included in the study if they met the following criteria: (1) MMS was cancelled because of the stay-at-home recommendations and rescheduled from April to August 2020 ("COVID-delay patients") and (2) MMS was performed between May and August 2019 ("control patients"). Electronic medical records were reviewed for patient demographics, tumor characteristics, and MMS outcomes (Supplementary Table I, available via Mendeley at https://10.1016/j.jaad.2021.11.052). The cancer worry scale, from the FACE-Q skin cancer module, was completed by all patients prior to surgery.2Lee E.H. Klassen A.F. Cano S.J. Nehal K.S. Pusic A.L. FACE-Q skin cancer module for measuring patient-reported outcomes following facial skin cancer surgery.Br J Dermatol. 2018; 179: 88-94Crossref PubMed Scopus (65) Google Scholar, 3Lee E.H. Klassen A.F. Lawson J.L. Cano S.J. Scott A.M. Pusic A.L. Patient experiences and outcomes following facial skin cancer surgery: a qualitative study.Australas J Dermatol. 2016; 57: e100-e104Crossref PubMed Scopus (68) Google Scholar, 4Lee E.H. Klassen A.F. Nehal K.S. Cano S.J. Waters J. Pusic A.L. A systematic review of patient-reported outcome instruments of nonmelanoma skin cancer in the dermatologic population.J Am Acad Dermatol. 2013; 69: e59-e67Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar The COVID-delay patients were asked 4 additional COVID-19–related questions (Table I). The patient and tumor characteristics as well as MMS outcomes were analyzed using descriptive statistics and frequency tabulation. Analysis of variance was used to evaluate whether certain factors influenced the cancer worry scores, and significant risk factors were analyzed using multivariate analysis of variance. All reported P values were 2 sided, and P values < .05 were considered statistically significant. The statistical analyses were performed using Stata, version 14.0 (StataCorp).Table IResults of the COVID-19–related questionsCombined (n = 143)BWH (n = 64)MSKCC (n = 79)What would you say your skin cancer worry compared with COVID-19 worry is: n (%) Less64 (45)35 (54)29 (37) The same40 (28)14 (22)28 (35) More31 (22)10 (15)21 (27)How did you feel when your treatment was delayed (select all): n (%) Understood the reason (COVID-19)119 (84)49 (75)72 (91) Understood the rationale (skin cancer treatment was not urgent)38 (27)18 (28)20 (25) Was upset about the delay14 (10)4 (6)10 (13)Did you develop any of the following symptoms after March 1, 2020? n (%) Cough5 (4)3 (3)2 (3) Fever0 (0)0 (0)0 (0) Sore throat0 (0)0 (0)0 (0) Nasal congestion or runny nose1 (1)2 (2)0 (0) Shortness of breath1 (1)0 (0)1 (1) Muscle aches0 (0)1 (1)0 (0) Anosmia1 (1)0 (0)1 (1)History of COVID-19, n (%)3 (2)0 (0)3 (4)BWH, Brigham and Women's Hospital; MSKCC, Memorial Sloan Kettering Cancer Center. Open table in a new tab BWH, Brigham and Women's Hospital; MSKCC, Memorial Sloan Kettering Cancer Center. Supplementary Table I (available via Mendeley). summarizes the details of 191 COVID-delay and 381 control patients (response rate, 75%). The mean time from biopsy to treatment was approximately 3 months longer for the COVID-delay group (COVID-delay patients: 129.0 days [SD, 97.9 days] vs controls: 41.0 days [SD, 44.3 days], P ≤ .0001). For MMS variables, there was no significant difference in pre- or postoperative defect size, the mean number of MMS stages, or the complexity of reconstruction. The mean cancer worry scale score was similar in all the patients (COVID-delay patients: 45.0 [SD, 17.9] vs controls: 44.7 [SD, 44.7], P = .9). The multivariate analysis of variance found higher equivalent cancer worry scores in patients with tumors ≥20 mm (+7.9), patients less than 65 years of age (+7.1), and female patients (+4.4). Table I summarizes the results of the COVID-19–related questions. About one-quarter of the COVID-delay patients were more worried about their skin cancer (31/143 [22%]), and only 10% (14/143) were upset about the delay. A prior history of cutaneous squamous cell carcinoma and tumor diameter of ≥20 mm were associated with being more worried about skin cancer, as determined using a univariate analysis, but neither were significant in the multivariate analysis (prior cutaneous squamous cell carcinoma: odds ratio, 1.9; 95% CI, 0.82-4.2; tumor diameter ≥20 mm: odds ratio, 2.5; 95% CI, 0.73-8.7). Surgical delays occur for many reasons, but the first wave of the pandemic created an opportunity to examine the impact of delays on emotional well-being and surgical outcomes. Surprisingly, a quarter of the COVID-delay patients were more worried about their KC than about a novel, life-threatening viral illness despite surgical outcomes not being affected. These data could be used to enhance patient-centered communication at the time of surgical delays, given the indolent nature of most KCs, which could alleviate cancer worry and improve the overall patient experience. None disclosed.