Impact of the COVID-19 Pandemic on the Diagnosis and Treatment of Cutaneous Melanoma in a Public Health Service in Brazil

J Clin Aesthet Dermatol. 2025;18(4):E61–E65.

by Ana Carolina da Silva Carvalho, MD; Carolina de Magalhães Ledsham Lopes, MD; Amanda Ribeiro Lobo; Isabela Almeida de Assis; Helena Lourenço de Medeiros; and Ana Paula Drummond-Lage, PhD

Drs. da Silva Carvalho, de Magalhães Ledsham Lopes, and Drummond-Lage are with Programa de Pós-Graduação em Ciências da Saúde, Faculdade Ciências Médicas de Minas Gerais – FCM-MG in Belo Horizonte, MG, Brazil. Mses. Lobo, de Assis, and de Medeiros are with Faculdade Ciências Médicas de Minas Gerais – FCM-MG in Belo Horizonte, MG, Brazil.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

ABSTRACT: Objective: The authors sought to evaluate the impact of the COVID-19 pandemic on the incidence, tumor thickness, and time between diagnosis and first treatment of cutaneous melanoma patients. Methods: A retrospective observational study was conducted based on the analysis of electronic medical records of patients treated at a reference service in Cutaneous Oncology within the scope of the Unified Health System in Belo Horizonte, Brazil. The population was evaluated according to the date of diagnosis and was classified into three periods: 1) pre-pandemic period (January 2019 to March 2020), 2) pandemic period 1 (April 2020 to June 2021), and 3) pandemic period 2 (July 2021 to September 2022). Sociodemographic characteristics of the study population, tumor characteristics, and the time interval between diagnosis and first treatment were evaluated. Results: Seventy-six patients were evaluated, 25 (32.89%) diagnosed in the pre-pandemic period, 22 (28.94%) in pandemic period 1, and 29 (38.15%) in pandemic period 2. No significant differences were observed between the sociodemographic characteristics of the population, tumor thickness, and the presence of ulceration in the three periods analyzed. There was also no delay between diagnosis and the first treatment during the pandemic. Limitations: The size of the population, and the use of retrospective data extracted from medical records, without a systematized record of information. Conclusion: The COVID-19 pandemic did not impact the incidence, thickness of melanomas, or the time between diagnosis and first treatment. This study demonstrated the importance of adapting the routine of health services and adapting the flow of oncology care in times of health crisis.

Keywords: COVID-19, melanoma, pandemic, SARS-COV-2

Introduction

Cutaneous melanoma is the most deadly skin cancer and its incidence is increasing worldwide.^1,2 It has a multifactorial etiology, depending on genetic and environmental factors, with ultraviolet radiation (sun exposure, or tanning beds), being the main environmental risk factor.³

The thickness of the primary tumor (Breslow) and ulceration represent the main prognostic factors, with early diagnosis and treatment determining the increase in cure rates.⁴ Patients with stage IA have a five-year survival rate of 99 percent, while those with stage IIID have just a 32 percent chance.⁵

On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 pandemic, caused by the coronavirus (Sars-CoV-2), responsible for an acute respiratory syndrome.⁶ The pandemic has had global repercussions on health services, making it difficult for the population to access them.⁷ In Brazil, the first case was diagnosed on February 26, 2020, with several health measures being adopted to control the disease, with a major impact on the routine of health services in 2020 and 2021.^8,9

In this scenario, studies were carried out to determine the effects of the pandemic on the incidence and mortality of cancers in general.^7,10,11 Published data show a decrease in the number of screenings and screening procedures, as well as a reduction in the number of diagnoses of colorectal, cervix, breast, and prostate tumors during the pandemic period.^7,10,11

Specifically concerning cutaneous melanoma, studies evaluated the periods of COVID-19 lockdown and the consequent impact on the diagnosis and morbimortality of this population, demonstrating a decrease in excised tumors and an increase in the thickness of diagnosed melanomas.^12–15 A Brazilian study identified a 156 percent reduction in hospitalizations for malignant skin tumors, comparing the first six months of 2020 with the same period of 2019.¹⁶ 

In this context, the objective of this study was to evaluate the impact of the COVID-19 pandemic on the diagnosis and staging of cutaneous melanoma within the scope of the Unified Health System (SUS) in Brazil.

Methods

Study design. An observational and retrospective study based on the analysis of electronic medical records of patients diagnosed with cutaneous melanoma from January 2019 to September 2022 in a reference unit for cutaneous oncology in the SUS, in Belo Horizonte, Brazil.

Study population. All patients treated at the study institution with a primary diagnosis of cutaneous melanoma confirmed by an anatomopathological report during the study period were included. Patients whose medical records did not contain anatomopathological and staging data were excluded from the study.

Collected variables.

• Sociodemographic. age, sex, marital status, skin color, place of residence, and date of anatomopathological diagnosis.
• Clinical. hereditary diseases with an increased risk of developing skin cancer (xeroderma pigmentosum, basal cell nevus syndrome, atypical nevus syndrome), family and personal history of previous skin cancer (melanoma, basal cell carcinoma or squamous cell carcinoma).
• Tumor characteristics. tumor topography, histological subtype, presence of ulceration, Breslow index, sentinel lymph node (SLN) biopsy status, staging, and clinical and surgical treatments performed.

The study population was evaluated according to the date of melanoma diagnosis, considering a pre-pandemic period and two periods during the pandemic. Each period comprised 15 months:

1. Pre-pandemic period: diagnoses carried out from January 2019 to March 2020.
2. Pandemic period 1: diagnoses carried out from April 2020 to June 2021.
3. Pandemic period 2: diagnoses carried out from July 2021 to September 2022.

The results are presented in frequency tables with absolute frequencies and their respective percentages, as well as descriptive measures (mean, median, standard deviation, minimum, maximum, and 25th and 75th percentiles) for quantitative data. Quantitative variables were tested for normality using the Kolmogorov-Smirnov. Simulation tests of Monte Carlo were used, chi-square test, ANOVA, Kruskal-Wallis, chi-square test of Pearson, chi-square test with the simulation of Monte-Carlo, and t-test. In all tests, the significance level adopted was 5 percent. The software used for the analysis was SPSS version 25.0. The project was approved by the institution’s Research Ethics Committee (CAAE 58888922.5.0000.5134).

Results

Seventy-six patients diagnosed with cutaneous melanoma were evaluated, 25 (32.89%) in the pre-pandemic period, 22 (28.94%) in pandemic period 1, and 29 (38.15%) in pandemic period 2. There was no statistically significant difference between the three groups regarding the variables age, sex, marital status, as well as risk factors such as xeroderma pigmentosum, basal cell nevus syndrome, and atypical nevus syndrome. Pandemic period 2 had a higher proportion of patients without a family history of melanoma (p=0.045) (Table 1). 

In Table 2, tumor characteristics were evaluated, such as topography, histological subtype, ulceration, Breslow index, and staging, with homogeneity concerning the periods evaluated (p≥0.05). 

Table 3 assesses the impact of the pandemic on the treatment of melanoma. No significant differences were observed in the treatments administered, including excision, excision with sentinel lymph node investigation, chemotherapy, and immunotherapy, among the three periods evaluated. The time between the date of anatomopathological diagnosis and the start of the first treatment was analyzed, with no difference between the periods (p=0.479). (Table 3). 

In Table 4, factors associated with tumor thickness were evaluated, with those with a tumor index being considered thin. Breslow< 1mm, and thick ≥ 1mm. The variables considered were sex, age, marital status, race, pandemic period, and time in days between the date of diagnosis and the first treatment, with no statistically significant differences, despite the predominance of thick melanomas in the pandemic period 2 (48.5%).

Discussion

The sample of this study included 76 patients, with the distribution of the number of cases in the three periods evaluated being similar. This finding differs from a study published by Barcaui et al,¹⁷ conducted at a university hospital in Rio de Janeiro, which reported a significant decrease in the number of diagnosed cases of primary melanoma in 2020. Superficial extensive melanoma was the most common histological subtype, as already reported in other studies.^18,19

When evaluating parameters such as gender, age, marital status, place of residence, Breslow index, and the presence of ulceration, there was no difference between the three periods. Highlighting the Breslow index, the main prognostic factor used in different studies during the COVID-19 pandemic to determine the severity of melanoma.^20–23 Corroborating our results, Klepfisch et al²² evaluated 1,046 melanomas, with no clinical or anatomopathological difference between the three periods evaluated: pre-lockdown, lockdown, and post-lockdown. Similar results were published by Gedeah et al²³ in a study conducted in Belgium. Other studies, however, reported results that differ from our findings. A systematic review of studies published in Europe and the United States showed an increase in Breslow thickness and TNM stage during the COVID-19 pandemic period,²⁰ data similar to the study of Seretis et al²¹ who reported a greater number of ulcerated melanomas and an increase in Breslow thickness after the pandemic. Similar results were published by Barcaui et al¹⁷ which also showed an increase in the severity of tumors in the period 2020/2021 when compared to the period of 2018/2019.

In this study, there was also no significant difference between the treatments instituted before and during the pandemic, with surgery being the most common. This result is in line with the most frequent diagnosis of thin and early-stage melanomas when surgery is the treatment of choice.²⁴

When we evaluated the time between the diagnosis of melanoma and the first treatment, there was no difference between the three periods evaluated, all with an average of less than 60 days. This finding is relevant, as in Brazil, one of the strategies to minimize delays in accessing cancer treatment was the enactment of the “60-day Law’ (Law 12.732/12), which provides that the patient diagnosed with cancer has the right to the first treatment in the SUS within 60 days from the date of diagnosis.²⁵ Corroborating this result, a study evaluating the impact of COVID-19 on patients with colon cancer carried out at the same institution demonstrated a decrease in the time between diagnosis and the start of systemic treatment during the pandemic period.²⁶ A possible justification was the adequacy of cancer patient flow at the study institution during the pandemic. In April 2020, all services were suspended at the dermatology outpatient clinic. In May 2020 there was a partial return, with cancer patients being prioritized. In 2021, there was a 68 percent increase in the number of skin oncology consultations when compared to 2019, according to data from outpatient care statistics from the SCMBH Medical Specialties Center. This strategy may have helped to absorb the possible pent-up demand due to the temporary suspension of services, without an increase in the severity of cases.

Limitations. The study has some limitations such as the size of the population, and the use of retrospective data extracted from medical records, without a systematized record of information.

Conclusion

No significant differences were observed in the number of cases and thickness of melanomas diagnosed in the three periods evaluated. The predominance of melanomas diagnosed at early stages during the pandemic period can be justified by the flow of care for cancer patients adopted by the institution during the pandemic. This study showed the importance of, in times of health crisis, adapting the routine of health services and adapting the flow of care, prioritizing emergency care, oncological diagnoses, and treatments.

References

1. Zhang W, Zeng W, Jiang A, et al. Global, regional and national incidence, mortality and disability-adjusted life-years of skin cancers and trend analysis from 1990 to 2019: an analysis of the Global Burden of Disease Study 2019. Cancer Med. 2021;10(14):4905–4922.
2. World Health Organization (OMS). Data visualization tools for exploring the global cancer burden in 2022. Accessed 15 Jan 2025. https://gco.iarc.fr/today/data/factsheets/cancers/16-Melanoma-of-skin-fact-sheet.pdf.
3. Naik PP. Cutaneous malignant melanoma: a review of early diagnosis and management. World J Oncol. 2021;12(1):7–19.
4. Keung EZ, Gershenwald JE. The eighth edition American Joint Committee on Cancer (AJCC) melanoma staging system: implications for melanoma treatment and care. Expert Rev Anticancer Ther. 2018;18(8):775–784.
5. Gershenwald JE, Scolyer RA. Melanoma staging: American Joint Committee on Cancer (AJCC) 8th Edition and Beyond. Ann Surg Oncol. 2018;25(8):2105–2110.
6. Organização Mundia de Saude (OMS). Histórico da pandemia de COVID-19. [acesso setembro/2023]. Disponível em: https://www.paho.org/pt/covid19/historico-da-pandemia-covid-19
7. Davis CH, Ho J, Greco SH, et al. COVID-19 is affecting the presentation and treatment of melanoma patients in the Northeastern United States. Ann Surg Oncol. 2022;29(3):1629–1635.
8. Ministerio da Saúde. COVID no Brasil. Accessed 15 Jan 2025. https://infoms.saude.gov.br/extensions/covid-19_html/covid-19_html.html.
9. Marques NP, Silveira DMM, Marques NCT, et al. Cancer diagnosis in Brazil in the COVID-19 era. Semin Oncol. 2021;48(2):156–159.
10. Englum BR, Prasad NK, Lake RE, et al. Impact of the COVID-19 pandemic on diagnosis of new cancers: a national multicenter study of the Veterans Affairs Healthcare System. Cancer. 2022;128(5):1048–1056.
11. London JW, Fazio-Eynullayeva E, Palchuk MB, et al. Effects of the COVID-19 pandemic on cancer-related patient encounters. JCO Clin Cancer Inform. 2020; 4:657–665.
12. Spurny-Dworak J, Steiner A, Breier F, et al. Effects of the COVID-19 pandemic on the diagnosis of malignant melanoma: a retrospective study. Eur J Dermatol. 2022;32(5):615–617.
13. Weston GK, Jeong HS, Mu EW, et al. Impact of COVID-19 on melanoma diagnosis. Melanoma Res. 2021;31(3):280–281. 
14. Tejera-Vaquerizo A, Paradela S, Toll A, et al. Effects of COVID-19 lockdown on tumour burden of melanoma and cutaneous squamous cell carcinoma. Acta Derm Venereol. 2021; 25;101(8):adv00525.
15. Troesch A, Hoellwerth M, Forchhammer S, et al. The impact of the COVID-19 pandemic on the diagnosis of cutaneous melanoma: a retrospective cohort study from five European skin cancer reference centres. J Eur Acad Dermatol Venereol. 2023;37(5):922–931.
16. Vilela IF, Carvalho TRW, Silva LR, et al. Impact of the COVID-19 virus pandemic on hospitalizations for skin cancer treatment in Brazil. Rev Bras Cir Plást. 2021;36(3):303–308.
17. Barcaui CB, Machado CJ, Piñeiro-Maceira J. Impact of the SARS-CoV-2 pandemic on the diagnosis of primary cutaneous melanoma at a university hospital in Rio de Janeiro. An Bras Dermatol. 2022;97(6):801–803.
18. Wainstein AJA, Duprat Neto JP, Enokihara MY, et al. Demographic, clinical, and pathologic features of patients with cutaneous melanoma: final analysis of the Brazilian Melanoma Group Database. JCO Glob Oncol. 2020;6:575–582. 
19. Saginala K, Barsouk A, Aluru JS, et al. Epidemiology of melanoma. Med Sci (Basel). 2021;9(4):63.
20. Toma AO, Prodan M, Reddyreddy AR, et al. The epidemiology of malignant melanoma during the first two years of the COVID-19 pandemic: a systematic review. Int J Environ Res Public Health. 2022;20(1):305.
21. Seretis K, Bounas N, Gaitanis G, et al. A meta-analysis on the impact of the COVID-19 pandemic on cutaneous melanoma diagnosis in Europe. Cancers (Basel). 2022;14(24):6085.
22. Klepfisch L, Carbonnelle-Puscian A, Faisant M, et al. Impact of the COVID-19 lockdown on the severity of newly-diagnosed primary cutaneous melanoma: a retrospective regional study in France. Ann Dermatol Venereol. 2023;150(1):49–51. 
23. Gedeah C, Damsin T, Absil G, et al. The impact of COVID-19 on the new diagnoses of melanoma. Eur J Dermatol. 2021;31(4):565–567.
24. Sladden MJ, Nieweg OE, Howle J, et al. Updated evidence-based clinical practice guidelines for the diagnosis and management of melanoma: definitive excision margins for primary cutaneous melanoma. Med J Aust. 2018;208(3):137–142. 
25. Planalto.gov.br. Presidência da República Casa Civil Subchefia para Assuntos Jurídicos. Accessed 20 Sep 2021. http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2012/lei/l12732.htm. 
26. de Oliveira RP, de Moraes PHR, Drummond-Lage AP. Impact of the SARS-CoV-2 on the journey of high-risk colon cancer patients within the scope of the Unified Health System in Brazil. BMC Health Serv Res. 2023;23(1):1102.