On March 30, 2020, The National Comprehensive Cancer Network (NCCN) released a second version of their advisory statement on the management of non-melanoma skin cancer (NMSC) during the COVID-19 pandemic.
“The advisory should be interpreted in the context of the practitioners’ local situations,” the authors said. “Physicians are encouraged to work with local authorities to comply with institutional and local guidelines, as well as be prepared to suspend excisional surgery if insufficient space, equipment or personnel are available to proceed safely.”
The general recommendations include:
- Multidisciplinary teleconferences should be used whenever possible for developing care plans for high-risk NMSCs, including MCC, that require treatment beyond office-based excision for local disease. These complex decisions should be made on a case-by-case basis using available resources and considering patient risk factors.
- Teleconference, using video and photographic evaluation, are encouraged for evaluating new tumors if possible.
- Follow-up using teleconference and/or photographs is encouraged for small lesions suspected of NMSC. Biopsies should be reserved for growing lesions or those that are highly concerning.
- If a small lesion is undergoing biopsy, physicians should obtain photographs with landmarks, such as tattoos, or have patients re-mark the site daily to facilitate accurate site location in case there is a delay.
Recommendations for NMSC, not including MCC:
- All excisions should be postponed during the COVID-19 pandemic.
- If NMSC poses a risk for metastasis or debilitating progression within 3 months, as estimated by the physician, excision may be considered. The risks posed by the tumor should be weighed against the risk of COVID-19 infection or asymptomatic transmission of infection to health care workers during care.
- Adjuvant therapy after surgical clearance of local excision is not recommended to be undertaken during this time due to the multiple visits needed and increased risk of COVID-19 transmissions. Exceptions to this recommendation are patients with extensive or multifocal invasion of large caliber nerves, clinical trials, and N2 disease (eg, multiple nodes involved, extranodal extension, a nodal disease focus over 3 cm) based on the 8th edition of the AJCC Cancer Staging Manual.
Recommendations for MCC include:
- Excisions are not recommended to be deferred during the COVID-19 pandemic, except for elderly or frail patients with tumors of less than 1 cm.
- If operating rooms are not available, office-based excisions using wide local excision with standard margins or Mohs surgery can be performed with deferral of sentinel lymph node biopsy (SLNB). Excisions should be allowed to granulate or closed primarily with cerclage or linear closure without undermining to facilitate SLNB at a later date.
- Multidisciplinary decision-making is recommended for patients with clinical stage III disease, and these decisions should be based on each patient’s medical comorbidities, degree of tumor burden, and scarcity of hospital resources.
In addition, the statement recommends the use of dissolving sutures to avoid return visits; telemedicine for postoperative care; and N-95 masks for patients with facial lesions undergoing surgery, especially for those on the nose or lips, along with eye protection, to prevent the risk of contracting or transmitting COVID-19.
The full statement is available here: https://www.nccn.org/covid-19/pdf/NCCN-NMSC.pdf
NCCN. Short-Term Recommendations for Cutaneous Melanoma Management During COVID-19 Pandemic: https://www.nccn.org/covid-19/pdf/Melanoma.pdf
AAD. Coronavirus Resources: https://www.aad.org/member/practice/managing/coronavirus
CDC. Information for Healthcare Professionals: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
CDC. Strategies for Optimizing the Supply of N95 Respirators: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html
FDA. Surgical Mask and Gown Conservation Strategies - Letter to Healthcare Providers: https://www.fda.gov/medical-devices/letters-health-care-providers/surgical-mask-and-gown-conservation-strategies-letter-healthcare-providers