Skin cancer: a hidden pandemic?

Posted: 28/04/2021

Skin cancer is highly treatable when detected early, but is an important area of health that has taken a back seat during the Covid-19 pandemic. It remains to be seen how widespread and damaging the impact of this will prove to be.

A study from Ontario found that there had been an 85% drop in skin biopsies at the onset of the pandemic [1]. Meanwhile, a study in the UK found a very similar trend during the first lockdown in early 2020, which concluded that skin cancer services should be resumed urgently at the end of the lockdown [2].

However, it is not just the NHS and health providers that have roles to play here. Everybody should be checking their bodies for skin cancer – the Skin Cancer Foundation recommends doing so once a month. A key reason for the reduction in referrals for skin cancers is the failure to have suspicious spots and skin blemishes checked by a practitioner. Many individuals know they have moles and perhaps consider having them checked but during the pandemic, such ‘routine visits’ to the GP or dermatologist have been foregone. However, such visits can save lives. There is a view, perhaps, that practitioners have more important things to do during a pandemic than check spots and blemishes, but with skin cancer, timing is so important.

So what should people be looking out for on their skin? The British Skin Foundation promotes the ABCDE acronym to establish whether moles need to be checked:

A - Asymmetry
B - Border
C - Colour
D - Diameter
E - Evolving

Key questions to ask include whether one half of the mole is different to the other; whether the border of the mole is poorly defined or erratic; whether there is more than one colour or shade in the mole; whether the mole is more than a quarter of an inch in diameter; and whether the mole changes in any way, including size, shape or colour. Other factors to look out for include crusting, bleeding or lesions that fail to heal. They may also itch.

Dermatologist and British Skin Foundation spokeswoman Dr Anjali Mahto advises looking "closely at the entire body including the scalp, buttocks and genitalia, palms and soles including the spaces between the fingers and toes" [3]. The eyes and ears should also be checked as these areas can sunburn easily.

Dermatologist Howard Stevens says melanomas can be “a wolf in sheep’s clothing” because they may look like innocent moles. If a large mole (greater than six millimetres in diameter) is growing or changing, get it checked! If a person has lots of moles, they should take extra steps to keep an eye on them.

Skin cancer is one of the most common cancers in the world and is generally very treatable but, if left unchecked, skin cancers can spread deeper and to other parts of the body. Furthermore, whilst most skin cancers are non-melanoma, more rarely, they can be melanoma cancers, which can be more serious. It is hard to determine whether skin cancer is melanoma purely from observation – even for medical practitioners. This underlines the importance of getting checked, so that a GP or dermatologist can refer a patient to a specialist if necessary.

Other types of non-melanoma skin cancer include basal cell carcinoma, which is often a small, shiny pink lump; squamous cell carcinoma, which appears as a pink lump with a crusted surface; Bowen’s disease, which appears red, scaly and may itch; and actinic keratoses, which are dry scaly patches caused by sun exposure.

Older people develop skin cancer more regularly and those with blue eyes and fair skin are also at an elevated risk. However, one in four skin cancer cases are diagnosed in people under 50 and anyone can get skin cancer – Bob Marley died of a skin cancer, which developed under his toenail, at the age of 36.

Cancers may also be harder to notice and therefore potentially more dangerous in people with darker skin. Patients from a BAME background, especially black people, are at higher risk of misdiagnosis and are more likely to have their skin cancer missed by practitioners. In the US, the five-year survival rate for melanoma has increased from 68% to 90% for white people since the 1970s. For black people during the same period, it has fallen from 67% to 66% [4].

Family history can be important too, and having a pre-existing large number of moles or freckles can increase the risk. Sun exposure is also a key cause of skin cancer, and this includes historic sunburn suffered as a child. And yes – it also includes sunbeds.

If a GP or dermatologist considers that a patient may have skin cancer, they will refer them to a specialist for a biopsy. If the diagnosis is confirmed, there will usually be surgery to remove the cancer. If the diagnosis is made early, surgery will usually be successful. However, if left longer before being diagnosed, cancer may require further treatment which can include radiotherapy, photodynamic therapy or, in serious cases, chemotherapy. Sometimes, moles will be removed as a precaution.

For squamous cell skin cancer, patients will have an urgent referral (within two weeks) while some less dangerous cancers may be referred to a specialist within 18 weeks on the NHS.

In the UK, there are around 147,000 new cases of non-melanoma skin cancer diagnosed each year and about 16,000 new cases of melanoma, which causes the deaths of more than 2,300 people every year. Alison Johnson, clinical negligence partner at Penningtons Manches Cooper, highlights the importance of preventative measures and early detection: “Check your body for new or changed moles, spots, and blemishes every month, and do not be afraid to attend your GP or dermatologist to ask for guidance. They are there to help and their opinion may save your life or prevent significant scarring from major surgery. Finally, avoid sunbeds - and use high SPF (30+) sun cream! I have represented people who have suffered a delayed diagnosis of skin cancers, for various reasons, and have seen how time is of the essence in terms of being able to treat these cancers successfully. If you feel that a medical practitioner has failed to consider your skin concerns adequately, failed to refer you for investigations or misdiagnosed a skin cancer, you may have a genuine claim for damages.”

This article has been co-written with Dominik Young, a trainee solicitor in the clinical negligence and personal injury team.

[1] Asai et al, 2021, ‘Impact of the COVID-19 pandemic on skin cancer diagnosis: A population-based study’.

[2] Nolan et al, 2020, ‘The effect of the COVID‐19 pandemic on skin cancer surgery in the United Kingdom: a national, multi‐centre, prospective cohort study and survey of Plastic Surgeons’.

[3] BBC News, 28 October 2020, ‘Skin cancer: How do I check my moles for signs of melanoma?’

[4] Guardian, 13 August 2020, ‘Decolonising dermatology: why black and brown skin need better treatment’.

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