Modified operations to permit safe and timely delivery of essential surgical care for high-risk skin cancer during a pandemic.

Abstract

Background: Many surgical practices closed at the onset of the COVID-19 pandemic raising concerns that delayed cancer care might impact patient outcomes. We implemented operational changes to safely remain open and treat tumors with potential to threaten life or function. We studied the impact of these changes on safety, access, and treatment. Methods: A single-center retrospective study was conducted in an academic office-based dermatologic surgery practice. All patients consented to research. Pre-pandemic (Nov. 2019 - March 21, 2020) consultations served as controls. Consultations during the pause (March 22 - June 8, 2020) and reopening (June 9 - Sept. 30, 2020) were evaluated for time to treatment, tumor area, and upstaging. One-way ANOVA or Fisher Exact analyses were performed with P < 0.05 significant. Operational changes included (1) modified scheduling, staffing, and rooming;(2) COVID-19 symptom screening;(3) N95 masks and shields for patient contact;(4) triage by tumor acuity;(5) same day or video consultation;and (6) increased utilization of same day biopsy and surgery for suspicious lesions. Results: Data from 698 patients (23-103 yrs of age, avg 71 yrs) yielded 876 tumors treated by Mohs surgery (n = 776), standard excision (n = 73), staged excision (n = 14) or electrodessication and curettage (n = 13). The average time from biopsy or consultation to treatment was faster during the pause and reopening relative to prepandemic (Table). More frozen section diagnostic biopsies were performed in the pause (n = 6) and reopening (n = 4) compared to pre-pandemic (n = 0). Post-operative defects were similar to prepandemic sizes (3.2 cm2 ) during the pause (3.9 cm2 ) and reopening (3.2 cm2 ) (p = 0.72). A reduction in treatment of basal cell carcinoma (BCC, X2 = 0.04) and shift toward treatment of higher risk tumors such as cutaneous squamous cell carcinoma (SCC, 49% of tumors during pause vs 37% pre-pandemic) and melanoma (11% pause vs 4.7% pre-pandemic) was noted. The percentage of SCC upstaged after treatment increased during the pause (42%, X2 = 0.02) vs pre-pandemic (18.5%) or reopening (17.4%). Conclusions: Time to treatment, tumor size, and SCC upstaging prepandemic and during the reopening fail to identify any significant access interruptions. This likely reflects practice modifications of increased same day surgery, frozen section diagnostic biopsy, and tumor triage. Lack of COVID-19 transmission attributable to maintained operations suggests that essential surgical care can be delivered safely to patients with high-risk skin cancers during a pandemic.