Impact of the COVID-19 virus pandemic on hospitalizations for skin cancer treatment in Brazil
Impacto da pandemia do vírus COVID-19 nas internações para tratamento de câncer de pele no Brasil

INTRODUCTION

Skin neoplasms are a broad group of diseases, and malignant neoplasms receive greater clinical emphasis due to their epidemiology and outcomes that are largely preventable with early treatment. Skin cancers are the most common neoplasms globally, with an estimated 2 to 3 million incidences in the non-melanoma type and 132,000 in melanoma per year¹. It is estimated that 1 in 3 diagnosed cancers occurs on the skin¹.

Brazil mirrors global epidemiology and has an estimated annual incidence of 185,380 cases by 2020, with 4,120 deaths in 2018. In this scenario, skin cancer is the neoplasm with the highest annual incidence^2,3.

Neoplasms are the second leading cause of mortality in Brazil, but most skin cancers have a good prognosis when diagnosed and treated early². This is why maintaining and improving cancer approach programs is important.

The year 2020 is being marked by the fatalities and changes required to cope with the COVID-19 virus. Therefore, this study’s importance is justified since it is necessary that, given the impact on skin neoplasms’ treatment due to the influence of the COVID-19 pandemic, it is important to look for means that minimize its consequences.

OBJECTIVES

This work aims to measure the evolution of hospitalizations in general for neoplasms and skin cancer in the period 2008-2020 and, from these data, quantify the impact on the number of hospitalizations for skin cancer treatment.

METHODS

An epidemiological study was conducted in the DATASUS database (TABNET) covering Brazilian municipalities from January 2008 to June 2020 regarding hospital admissions, elective and urgent hospitalizations, for the treatment of chapters ICD-10, “malignant neoplasm of the skin,” and “other malignant neoplasms of the skin”⁴.

This was followed by normative resolution number 510 of April 7, 2016, of the Ministry of Health, which defines the researches that use public access information, made in databases, whose information is aggregated, without the possibility of individual identification and do not need to go through the research ethics committee (CEP)⁵.

The information system of the Ministry of Health has already published data for the first six months of 2020 and, for this reason, was the period of choice determined to create parallelism with previous years regarding the number of hospitalizations in the chosen groups, the character of hospitalization (elective x urgency) and percentage evolutions. These data were analyzed by the authors of this study in meetings at Santa Casa de Montes Claros.

RESULTS

The hospitalizations performed in the Unified Health System, between January and June 2008 and 2020, were tabled and analyzed, resulting in figures 1A, 1B and 1C and Table 1. There was an increase in the total number of hospitalizations for all causes from 2008-2019: the total number of hospitalizations increased 10.60%, the number of hospitalizations for neoplasms increased 58.65%, and the total number of hospitalizations for skin cancer increased by 156.24%.

Figure 1 - Annual evolution of hospitalizations in Brazil from January to June 2008 to 2020. A. Evidences the evolution of hospitalizations for all causes, neoplasms and skin cancer in the SUS, in the first 6 months of each year, in millions; B and C. Are specific of neoplasms skin cancers, respectively, in the first 6 months of each year, in thousands.

Figure 1 - Annual evolution of hospitalizations in Brazil from January to June 2008 to 2020. A. Evidences the evolution of hospitalizations for all causes, neoplasms and skin cancer in the SUS, in the first 6 months of each year, in millions; B and C. Are specific of neoplasms skin cancers, respectively, in the first 6 months of each year, in thousands.

Table 1 - Number of general hospitalizations, neoplasms and skin cancer in Brazil in the first six months (2008-2020).

The first six months of 2020 showed a numerical reduction in hospitalizations in the three groups compared to the same months of 2019: general hospitalizations reduced by 26.69%, hospitalizations for all neoplasms reduced by 26.12%, while malignant skin neoplasms reduced by 33.03%.

The percentage changes over the previous year, in the first six months of each year, 2008-2020, are recorded in figure 2.

Figure 2 - Percentage change in hospitalizations in Brazil from January to June 2008 to 2020.

Figure 2 - Percentage change in hospitalizations in Brazil from January to June 2008 to 2020.

The number of hospitalizations for skin cancer studied in the first six months of the period is shown in Figure 3 and Table 2.

Figure 3 - Number of hospitalizations for skin cancer treatment in the first six months of each year, from 2008 to 2020, in Brazil.

Figure 3 - Number of hospitalizations for skin cancer treatment in the first six months of each year, from 2008 to 2020, in Brazil.

Table 2 - Hospitalizations for skin cancer treatment in Brazil in the first six months (2008-2020).

Figure 4 shows the evolution of elective and urgent hospitalizations for skin cancer treatment from January to June 2008 to 2020.

Figure 4 - Numerical evolution of elective and urgent hospitalizations for skin cancer treatment from January to June 2008 to 2020.

Figure 4 - Numerical evolution of elective and urgent hospitalizations for skin cancer treatment from January to June 2008 to 2020.

DISCUSSION

The direct and indirect impact of COVID-19 infection is not yet fully known. The possible theorized indirect results are reduced hospitalizations to other diseases due to the scarcity of SUS resources or its contingency. Another French study, still in progress, confirms in its preliminary reports a similar trend, with a drastic reduction in terms of screening (-86%), diagnosis (-39%) treatment (-30%) when compared to the same period of 2019⁶.

The analysis of figures 1 and 2 and table 1 revealed that there was an increase in hospitalizations in the three groups from 2008 to 2019: general hospitalizations increased by 582,326 (10.60%), hospitalizations for cancer in general increased by 159,775 (58.65%), and hospitalizations for skin cancer increased by 16,905 (156.24%).

The comparison of the first six months of 2019 and 2020 revealed a reduction in the total and the proportional number of hospitalizations: general hospitalizations decreased by 1,622,198 (26.69%), cancer in general in 112,893 (26.12%) and skin cancer in 9,158 (33.03%).

The drop in the number of hospitalizations shows how skin cancer treatment may have been affected, similar to what occurred in England, where there was a statistically significant reduction in skin cancer diagnoses of 68.61%⁷.

Monthly hospitalizations for skin cancer in 2020 gradually reduced. January 2020 still increased compared to 2019, while February, March, April, May and June 2020 were equivalent to the number of hospitalizations with the same months of 2019, 2016, 2010 and before 2008. The impact of this change is best understood in Figure 5.

Figure 5 - Monthly variation of hospitalizations for skin cancer in the first six months, from 2008 to 2020, in Brazil.

Figure 5 - Monthly variation of hospitalizations for skin cancer in the first six months, from 2008 to 2020, in Brazil.

In line with other international projections, this trend in reducing the number of cases treated may lead to a late diagnosis, with a worse prognosis in this cancers⁸.

Figure 4 shows that the rates of elective and urgent surgeries maintained their general downward trend from 2008 (40% of urgent surgeries) until 2020 (19.88%), with small variances, which shows no change to urgency in elective cases.

Given the absence of adequate diagnosis and treatment, there can be a considerable increase in severity cases, according to studies by Tejera-Vaquerizo et al. (2020) ⁹, which estimated increased size and depth of squamous cell carcinoma and melanomas in Spain during the pandemic. It was noticed in this study when there is a delay of 3 months in the diagnosis the projection and reduction of the survival in 5 years of 5.2% for squamous cell carcinoma (SCC) and up to 30.2% months for the melanoma.

CONCLUSION

This study shows that SUS resources’ contingency led to a reduction in the total number of hospitalizations, returning to lower monthly levels than 12 years ago. This isolated data is an important indication of the indirect impact of the COVID-19 pandemic, as it represents real, measurable and up-to-date data on the change of approaches to other pathologies in this particular period.

Due to the delay in the various stages of approach to skin cancers, efforts should be made to minimize the pandemic’s impact. In this context, we can highlight the standardization of conducts, according to guidelines developed by institutions, such as the National Comprehensive Cancer Network¹⁰. Besides, it is necessary to facilitate the patient’s access to the health system, and telemedicine, cited in several sources as a facilitator of the follow-up of these cases, is necessary ^7,11,12.

In the specific case of skin cancer requiring reconstruction in a hospital environment (and not just outpatient), these are patients with complex lesions. A few months may undoubtedly represent the difference between curative surgery or just oncological (palliative) hygiene. Due to acute and chronic diseases, the mortality curves presented in the coming years will attest to the meaning of this fall in hospitalizations.