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Collateral damage to elderly patients presenting with advanced skin cancer. Another toll to pay due to COVID-19 pandemic

1 Department of Plastic and Reconstructive Surgery, Usl Umbria 1, Via Guerra 21, 06127 Perugia, Italy
2 ENT and Head and Neck Surgery, Usl Umbria 1, Via Guerra 21, 06127 Perugia, Italy
3 Translational Medical and Surgical Sciences, PhD Program, University of Parma, 00198 Rome, Italy
4 My Self clinic, Via Isonzo 32, 00198 Rome, Italy

Date of Submission19-Feb-2021
Date of Decision09-Mar-2021
Date of Acceptance11-Mar-2021
Date of Web Publication29-Jun-2022

Correspondence Address:
Giuseppe Guarro,
Translational Medical and Surgical Sciences, PhD Program, University of Parma, 00198 Rome
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_189_21

How to cite this URL:
Lapalorcia LM, Mobaraki PD, Guarro G, Maffia R, Finocchi V, Cordellini M. Collateral damage to elderly patients presenting with advanced skin cancer. Another toll to pay due to COVID-19 pandemic. Indian J Cancer [Epub ahead of print] [cited 2022 Dec 4]. Available from:

Skin exposure to UVB (Ultraviolet B), genetic predisposition, cigarette smoke, and environmental factors favor the incidence of skin cancer in the Caucasian population, as widely described in the literature and confirmed recently.[1] Life expectancy in Italy is one of the highest in the world,[2] and the general population is believed to be healthy because of a healthy lifestyle and Mediterranean diet. Family medicine and public health care are founded on the principles of socialized medicine, and the population has access to medical and surgical care at basically no cost.[3]

Dermatology consultations are available with a short waiting list, and patients requiring surgical excision of skin lesions are addressed in public reconstructive surgery units that provide standard excision of said lesions. The impact of the COVID-19 (coronavirus disease 2019) pandemic has been dramatic not only in rural areas worldwide but also in metro areas that have deeply been affected due to the suspension of elective surgery procedures and nonurgent consultation.[4] Collateral damage is defined as an injury inflicted on something other than the intended target, according to Webster's dictionary. Civilians during a military operation, casualties, bystanders, people in the wrong place at the wrong time, and similarly, patients who would normally have access to diagnosis and treatment but do not because of lockdown measures, and displacement and misuse of resources can be identified as some examples.

Development and growth of skin cancer such as basal cell carcinoma and squamous cell carcinoma are exponential, and potentially benign lesions tend to become large and aggressive if early excision is not performed.

Elderly patients with comorbidities are also less likely to receive anesthesia clearance because of long-lasting and complex surgical operations increasing the morbidity and mortality rates of a potentially benign and localized oncologic disease.[5]

We report two cases diagnosed within a time interval of 10 days that occurred in relatives of health care workers and witnessed a dramatic trend in the increase of advanced cancer that will be seen in the next months, and maybe years, if resources and screening policy do not return to the norm.

The first case was a 90-year-old woman introduced to our plastic surgery department presenting with a 15-week history of injury on the nose [Figure 1]. The patient had a previous history of two squamous cell skin carcinomas of the vertex and left ear. Although the first diagnosis was made by her general practitioner, the small nodule became larger during the spring and summer of 2020. Clinical investigation revealed a dramatically large, red nodule characterized by a central ulcer (5 cm × 3.5 cm in the middle). The preliminary histologic evaluation revealed neoplastic cells, with atypical cytological features of the usual squamous cell carcinoma (SCC). Atypical keratinocytes could not be noticed at the level of the interfollicular epidermis. The computed tomography (CT) scan revealed cervical as well as parotid lymph node metastases [Figure 2]. A radical excision was then performed. The second case was a 75-year-old woman who had noticed a little red knob on the left side of her nose a year before her underlying introduction to us. Although the histologic diagnosis was SCC, the lesion expanded. Thus, the pandemic dramatically delayed our first evaluation (5 months). The clinical examination uncovered an inadequately outlined, dim-red knob with a sporadically formed ulcer in the middle, measuring 3 cm × 2 cm on the left side of her nose [Figure 3]. The neoplastic cells showed the atypical cytological highlights of an ordinary SCC. After the preliminary incisional biopsy, a radical excision was performed.
Figure 1: A 90-year-old patient presenting with a 15-week history of injury on the nose

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Figure 2: CT scan of Patient 1

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Figure 3: A 75-year-old patient presenting with an evolving squamous cell carcinoma (left and right) on the left side of the nose

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Since the first case that occurred in China, in December 2019, the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; COVID-19) disease has quickly spread around the world and has been declared as a pandemic in 2020 by the World Health Organization. The number of infected patients has dramatically increased since then. This situation has hit hard the international health care systems, which have been forced to set up COVID hospitals, with separate pathways for positive and nonpositive patients. This has led to a large number of delays in clinical diagnoses. For patients with cancer, delay of surgery brings the perspective of an increase in the metastatic disease, with some patients' clinical pattern progressing from curable (characterized by a near-normal life expectancy) to noncurable (characterized by a limited life expectancy). Delay in diagnoses of urgent skin cancers would result in patients presenting later with significantly advanced disease, requiring more extensive surgery, and receiving worse surgical assistance.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Wilken R, Criscito M, Pavlick AC, Stevenson ML, Carucci JA. Current research in melanoma and aggressive nonmelanoma skin cancer. Facial Plast Surg 2020;36:200-10.  Back to cited text no. 1
Liou L, Joe W, Kumar A, Subramanian SV. Inequalities in life expectancy: An analysis of 201 countries, 1950-2015. Soc Sci Med 2020;253:112964.  Back to cited text no. 2
European Physical and Rehabilitation Medicine Bodies Alliance. White book on physical and rehabilitation medicine (PRM) in Europe. Chapter 8. The PRM specialty in the healthcare system and society. Eur J Phys Rehabil Med 2018;54:261-78.  Back to cited text no. 3
Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine 2020;21:100331.  Back to cited text no. 4
Basu P, Beckles A, Porter ML, Olbricht S. Nonmelanoma skin cancers are more likely to be untreated in elderly patients. J Am Acad Dermatol 2020;82:505-7.  Back to cited text no. 5


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