








key: cord-300995-tqz2bkdo
authors: Tagliaferri, Luca; Di Stefani, Alessandro; Schinzari, Giovanni; Fionda, Bruno; Rossi, Ernesto; Del Regno, Laura; Gentileschi, Stefano; Federico, Francesco; Valentini, Vincenzo; Tortora, Giampaolo; Peris, Ketty
title: Skin cancer triage and management during COVID‐19 pandemic
date: 2020-04-25
journal: J Eur Acad Dermatol Venereol
DOI: 10.1111/jdv.16529
sha: 
doc_id: 300995
cord_uid: tqz2bkdo

The worldwide medical community is striving to pursue the most appropriate clinical choices in the worst event of pandemic of the modern times [1], with over 1 million patients affected by COVID‐19 (i.e., swab positive patients with or without symptoms) reported so far [1]. In this context, the aim of the ideal management of cancer patients is to achieve the best possible balance between the two different issues to be considered, which include the risk of cancer progression and the risk of infectious disease.

This article is protected by copyright. All rights reserved

The worldwide medical community is striving to pursue the most appropriate clinical choices in the worst event of pandemic of the modern times [1] , with over 1 million patients affected by COVID-19 (i.e., swab positive patients with or without symptoms) reported so far [2] . In this context, the aim of the ideal management of cancer patients is to achieve the best possible balance between the two different issues to be considered, which include the risk of cancer progression and the risk of infectious disease. In detail, the risk to develop COVID-19 disease in the setting of oncological patients can be stratified into three scenarios: a) to prevent a patient with advanced skin cancer who is COVID-19 negative to be exposed to viral infection; b) to prevent a patient with advanced skin cancer who is COVID-19 positive to infect the health professionals; c) to prevent a patient with advanced skin cancer COVID-19 positive to infect other patients. In Italy as well as in Europe, since the beginning of March 2020, we are in the front line of the pandemic and therefore we felt that it might be useful and ethical to share how we faced these issues [3, 4] .

We suggest practical recommendations about follow-up and treatment of skin cancer patients during the COVID-19 pandemic. Our University Hospital is one of the largest COVID-19 referral 

This article is protected by copyright. All rights reserved Regarding the literature search, no specific papers about the topic were identified. Therefore, the proposal was to meet twice monthly instead of once weekly, with the following rules: 1) only one specialist for each discipline can be physically present at the tumour board Meeting (no residents allowed); 2) the room identified to hold the meeting allows to have at least 1.5 meters of distance among the participants; 3) all other participants can take part to the meeting through a dedicated teleconference platform that guarantees the audio-video participation of doctors and sharing of radiological images, photographic documentation and medical records; 4) the possibility to gather the S-MDTB for urgent cases before the scheduled meetings through teleconference.

As for the management of the clinical workload, the S-MDTB decided to identify three major classes of skin tumours according to their biological aggressiveness, i.e. advanced Melanoma and advanced Squamous Cell Carcinoma (SCC) and Basal Cell Carcinoma (BCC).

The main recommendations for patients' management are reported in Table 1, 2 and 3 respectively.

A major limiting factor in our daily practice is the reduced number of available anaesthetists and operating rooms, with the consequent need to elaborate a patients' priority list according to individual oncological prognosis, health condition and comorbidities. In case of symptomatic patient or suspected SARS-CoV-2 infection, the recommendation is to wait until swab result is ready (12-24 hours) and act according to the result.

We use a "triage" colour system to better identify the different situations:

-Red: The COVID-19 risk might be higher than the oncological risk. In this case, we postpone the patient's visit or treatment.

-Yellow: The COVID-19 risk might be high for patients and health care professionals, and the final decision takes into account the feasibility of required procedures, the oncological risk and patient's age and comorbidities on a patient-by-patient basis. The S-MDTB may decide to postpone the visit or therapy or switch to other type of treatments.

-Green: The COVID-19 risk is less than the oncological risk (i.e. a patient with a clear-cut melanoma or a patient with advanced skin cancer under systemic treatment or radiotherapy): the patient must be treated or continue his/her treatment.

-White: The COVID-19 risk is low, and the delay of treatment does not considerably affect the prognosis -the team discusses with the patient the alternative therapeutic approaches, which may represent the best option during the pandemic and possible schedule time.

This article is protected by copyright. All rights reserved We therefore propose that the oncological risk and the risk of SARS-CoV-2 infection need to be considered and balanced in order to provide a weighted and controlled strategy to advanced skin cancer patients. A useful approach, as already suggested by other authors, is to identify the different classes of priorities, both for the patients and for health professionals [5, 6] .Only a few national and international societies have released specific recommendations for skin cancer patients [7] . It is important to underline that in order to consider patients to be COVID-19 negative they have to be asymptomatic and with no history of previous exposure, while in case of symptoms or history of previous exposure it is necessary to confirm the negativity with a swab [8] based on the internal Hospital and national recommendation [9] .

The clinical activities should be managed in a different way for patients COVID-19 positive.

Specific clinical conditions must be evaluated on an individual basis (e.g. young patient with invasive melanoma requiring sentinel node biopsy) discussing the priority list of operating rooms in case of limited access or limited availability of anaesthetists. When surgical treatment for advanced SCC or BCC is unfeasible, radiotherapy should be considered as an alternative option, mainly for elderly patients. As far as follow-up visits are concerned, they could be managed by implementing a dedicated system of telemedicine unless the patient reports side effects, relapse or worsening of disease, which might instead require access to the Hospital. Notably, the Italian Medicines Agency (AIFA) has facilitated the bureaucratic procedures allowing cancer patients under treatment with oral anti-tumour drugs to directly collect the medications by the Pharmacy Hospital without medical prescription for the next 3 months. In addition, due to the lockdown, the Italian Civil Protection offers a home drug delivery service available throughout the entire Country.

For patient who need to come to the Hospital for the cure, some rules must be abided: a) only patients and no caregivers are allowed to enter the Hospital, b) patient's body temperature is checked at the main entrance of the Hospital or at the Department, c) each individual in the Hospital must wear a mask and gloves, and must keep at least 1.5 m inter-personal distance [10] .

For patients under treatment with radiotherapy or systemic therapy who become COVID-19 positive, the treatment should be discontinued or discussed on an individual basis involving the infectivologists. A unique pathway for COVID-19 positive patients who still need to be treated is under investigation at the Radiology and Radiotherapy Departments of our University.

This article is protected by copyright. All rights reserved 

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Centre for Disease Control and Prevention

European Centre for Disease Prevention and Control. Situation update worldwide

The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy

European Task Force on Atopic Dermatitis (ETFAD) statement on severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2)-infection and atopic dermatitis

COVID-19 outbreak in northern italy: first practical indications for radiotherapy departments

Global coronavirus pandemic (2019-nCOV): Implication for an Italian medium size dermatological clinic of a ii level hospital

Società Italiana di Dermatologia medica, chirurgica, estetica e delle Malattie Sessualmente Trasmesse (SIDeMaST)

The Royal College of Radiologists. Coronavirus (COVID-19): cancer treatment documents

Pandemic Planning Clinical Guideline for Patients with Cancer

Guidance document for risk assessment and management of patients and healthcare professionals in radiation oncology departments during ongoing covid-19 spread

The authors would like to thank the S-MDTB: Roberta Albanese, Mario Balducci, Maria 

This article is protected by copyright. All rights reserved

