The importance of Early Detection in the light of COVID-19

Melanoma has a poor prognosis with median survival of 6-9 months in the absence of timely diagnosis and treatment.

Thanks to the introduction of novel, highly effective but also costly therapies (immune therapies with anti-PD1 and anti-CTL4, and targeted therapies for BRAF mutant melanoma), overall survival has now considerably increased to over 50% at five years¹.

In this setting, access to early diagnosis and surgical treatment, as well as continuous access to systemic therapies and monitoring, are critical for the survival of our patient population. Under Covid-19, we have already witnessed a dramatic decrease in cancer diagnoses across all cancers, including melanoma². Early detection of melanoma was, even before the pandemic, a critical aspect in Eastern European countries such as Romania³. Additionally, the Romanian healthcare system is known as one of the most under-performing in Europe and has for several years in a row ranked last in the EHCI reports^4-6, thus we expected that access to screening and melanoma care would become rapidly critical.

Under the Covid pandemic and considering the large number of patient complaints we had in our online forums, and the worrying data reported by the Romanian Health Observatory⁷,  the Romanian Melanoma Association and Melanoma Patient Network Europe (MPNE) initiated a study to capture how the lock-down affected the access to health care and how to potentially mitigate its negative effects. Our survey was completed by 108 respondents, members of the Romanian Melanoma Association, in the springtime of 2020.  62% were patients and 38% caregivers, who completed the questionnaire on behalf of the patient. We were not surprised to see that even in the early days, the Covid-19 pandemic has impaired the access to melanoma care for 40% of Romanian melanoma patients.

Comparable data reported in the Netherlands showed that 30% of cancer patients experienced access issues to their oncological treatment or follow-up⁸, making our results consistent with the overall lower performance of the Romanian healthcare system^4-6. What was the most worrying aspect is that more than 50% of patients delayed investigations such as dermoscopy, imaging and laboratory tests by their own initiative, while a third saw investigation delayed upon their physician’s initiative. Early-stage and stable patients were more likely to give up on their regular consultations, while those with melanoma progression were the most concerned. The fact that it was predominantly patients rather than physicians who delayed dermatological controls and follow-up visits by their own initiative means that even with sufficient protective measures in place, melanoma patients will need to be proactively informed about the risk of melanoma and reassured of their safety in order to seek care.

Education on secondary prevention and early detection, especially in the first years after diagnosis, seems to be paramount. Our respondents were either members of our Romanian Melanoma Association and MPNE or followers, meaning more likely to be proactive, educated patients. Therefore, we consider these results as the ‘best possible scenario’’, with even worse outcomes for those patients less able to understand their risk of melanoma or to navigate the Romanian healthcare system. This means that patients from countries with already lower healthcare performance and less exposure to early detection measures will now be disproportionally affected by Covid delays in cancer diagnoses.  To avoid the spiralling out of control of the melanoma situation in countries like Romania, we, therefore, see an urgent need to implement innovative models for early detection both for melanoma patients and high-risk populations to at least dampen the future impact of Covid-19 or on outcomes in melanoma.

Our results were published in the Journal of Radiotherapy and Medical Oncology⁹.

References

1. Larkin, J. et al. Five-Year Survival with Combined Nivolumab and Ipilimumab in Advanced Melanoma. New Engl J Med 381, 1535–1546 (2019).
2. Dinmohamed, A. G. et al. Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands. Lancet Oncol 21, 750–751 (2020).
3. Forsea, A. M., Marmol, V. del, Vries, E. de, Bailey, E. E. & Geller, A. C. Melanoma incidence and mortality in Europe: new estimates, persistent disparities. British Journal of Dermatology 167, 1124–1130 (2012)
4. Euro Health Consumer Index 2018. https://healthpowerhouse.com/media/EHCI-2018/EHCI-2018-report.pdf
5. Euro Health Consumer Index 2017. https://healthpowerhouse.com/media/EHCI-2017/EHCI-2017-report.pdf
6. Euro Health Consumer Index 2016. https://healthpowerhouse.com/media/EHCI-2016/EHCI-2016-report.pdf
7. Impactul Pandemiei COVID 19 asupra bolnavilor cronici_septembrie 2020-1.docx. https://health-observatory.ro/wp-content/uploads/2020/10/Raport_ORS-impact_pandemie_cronici_2020.pdf
8. De Joode, K. et al. Impact of the coronavirus disease 2019 pandemic on cancer treatment: the patients’ perspective, European Journal of Cancer. Volume 136, 132 - 139
9. Violeta Astratinei, Andreea Strambu-Dima, Bettina Ryll, Critical Issues in Melanoma Follow-up and Treatment, Safety of Patients and Communication with Healthcare Professionals During Covid-19 Pandemic in Romania. Journal of Medical and Radiation Oncology 1, 15-33 (2021)

About the author

Violeta Astratinei is a Ph.D. biologist and a Patient Advocate, passionate about  research in the prevention and treatment of Melanoma. After losing her sister to Melanoma in 2014, she joined Melanoma Patient Network Europe (MPNE) and founded the  Romanian Melanoma Association, As a Romanian living in the Netherlands, she is involved in research and education at Dutch Melanoma Foundation. Near to iTobos, she participated in European projects like Share4Rare and  UMCure. In 2019, she joined EORTC Melanoma Steering Committee as the first Patient Advocate to offer the advocacy perspective on clinical research.