key: cord-1015822-0f65993s
authors: Earnshaw, C.H.; Hunter, H.J.A.; McMullen, E.; Griffiths, C.E.M.; Warren, R.B.
title: Reduction in skin cancer diagnosis, and overall cancer referrals, during the COVID‐19 pandemic
date: 2020-06-04
journal: Br J Dermatol
DOI: 10.1111/bjd.19267
sha: 390e06b2df68349ccf85426e76645ca3c357b2de
doc_id: 1015822
cord_uid: 0f65993s

The COVID‐19 pandemic has led to a marked reduction in the number of patients accessing the UK’s National Health Service (NHS) for emergency reasons(1). The cause for this decline is as yet unknown, and likely to be multifactorial. We investigated whether there had been a similar reduction in urgent cancer referrals (known in England as the Two Week Wait (TWW) pathway) and subsequent diagnosis of skin cancer in our dermatology service.

reduction in urgent cancer referrals (known in England as the Two Week Wait (TWW) pathway) and subsequent diagnosis of skin cancer in our dermatology service.

Malignant melanoma (MM) is the 5 th most common cancer in the UK 2 . Cutaneous squamous cell carcinoma (SCC) also has a significant risk of mortality 3 . The early diagnosis of MM and SCC is critical to improving patient survival 4 , a principle that applies to all cancers.

The number of TWW referrals our department has received over the past 5 years has increased ( Figure 1A ). Using our cancer tracking database, we identified a dramatic 34.3% reduction in referrals in February-April 2020 compared to the same period in 2019 ( Figure 1B ). The largest decrease was in April 2020 (335 TWW referrals received (56.4% lower than April 2019 (768)).

More concerning is the number of skin cancers diagnosed in patients referred on the TWW pathway in March 2020 decreased compared to previous years (28 in March 2020, 52 in March 2019, Figure 1C ). Using our average conversion rate (percentage of TWW referrals with a histological diagnosis of skin cancer) over the last 5 years (6.95%), and based on the average increase in referrals, we expected to diagnose 125 MM and SCC in March and April 2020.

This article is protected by copyright. All rights reserved Assuming the conversion rate remains stable, this number will drop to 59; a 53% reduction. The reduction in referrals and subsequent skin cancer diagnoses in our patient population is a major concern. Ultimately, many of these cases may present with more advanced disease and poorer outcomes as a consequence.

We investigated whether this trend was observed across a range of other TWW cancer referral pathways in our hospital. We report here the same concerning pattern of decreased referrals across a wide variety of cancer types ( Figure 1D ).

During the post-COVID pandemic recovery phase there may be a significant rebound wave of TWW skin cancer referrals to dermatology departments across the country. This may further test already stretched resources. Predicting this peak will enable advance planning of the provision of appropriate clinic capacity and associated levels of staffing.

The detrimental consequences of the COVID-19 pandemic to clinical practice will not be understood for some time to come. These findings are a wake-up call to prepare for an upswing in skin cancer referrals later this year. The findings also suggest this trend in referrals may lead to delayed diagnosis, with poorer prognosis, of a wide range of cancers. 

A&E and Emergency Admissions 2019-20. Available at

Update on Keratinocyte Carcinomas

Melanoma staging: evidence-based changes in the

American Joint Committee on Cancer eighth edition cancer staging manual

We would like to thank David Muskett, Andrew Gardner and Rebecca Thompson for assisting with data collection from the histopathology labs and the Cancer Tracking Service at Salford Royal Hospital.