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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Due to the Coronavirus Disease 2019 &#40;COVID-19&#41; pandemic&#44; many countries went into lockdown&#44; which began in Spain on March 14<span class="elsevierStyleSup">th</span> 2020&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most surgeries and appointments were canceled&#44; and the population was concerned about getting infected&#46; Therefore&#44; patients are mainly consulted for severe symptoms&#46; This could lead to a reduction in the diagnosis of different diseases such as skin cancer&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> heart attacks&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or strokes&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and a compromise of cancer screening programs&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> In the case of melanoma&#44; a recent study estimated an upstaging of 45&#37; of invasive melanomas after a 3-month delay&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although some authors noted a reduction in the number of diagnosed melanomas during the lockdown&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a> other studies showed the opposite results&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> However&#44; since most articles limited the studied period to the lockdown it is only possible to estimate the impact of the delay in melanoma diagnosis&#46; We compared the melanomas diagnosed after the lockdown&#44; not only short-term but also once the normal clinical activity was restored&#44; in order to assess if the diagnosis delay due to the COVID-19 lockdown actually meant a prognosis worsening of the melanomas&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">A retrospective&#44; single-center&#44; observational study of histopathologically diagnosed melanomas between March 14<span class="elsevierStyleSup">th</span> 2019&#44; and March 13<span class="elsevierStyleSup">th</span> 2021 was designed&#46; This study was approved by the Institutional Ethics Committee&#46; The data was retrieved from the Pathology Department records of our hospital&#46; Demographic data&#44; referral via teledermatology&#44; melanoma location&#44; Breslow thickness &#40;mm&#41;&#44; presence of mitosis and ulceration&#44; and AJCC &#40;American Joint Committee on Cancer 8<span class="elsevierStyleSup">th</span> edition&#41; staging were collected&#46; Incidence was calculated per 100&#46;000 inhabitants&#46; Metastatic melanoma and clinically diagnosed melanoma without histopathological confirmation were excluded&#46; The first 6-month period following the start of the lockdown&#44; between March 14<span class="elsevierStyleSup">th</span> 2020&#44; and September 13<span class="elsevierStyleSup">th</span> 2020 &#40;1<span class="elsevierStyleSup">st</span> P20&#41;&#44; and a second 6-month period between September 14<span class="elsevierStyleSup">th</span> 2020&#44; and March 13<span class="elsevierStyleSup">th</span> 2021 &#40;2<span class="elsevierStyleSup">nd</span> P20&#41; were compared with the same periods of the previous year &#40;1<span class="elsevierStyleSup">st</span> P19 and 2<span class="elsevierStyleSup">nd</span> P19&#44; respectively&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using R &#40;R Core Team&#44; Vienna&#44; Austria&#41;&#59; <span class="elsevierStyleItalic">t</span>-test and <span class="elsevierStyleItalic">U</span>-Mann Whitney were used for quantitative variables&#46; Fisher&#8217;s exact test was used for the analysis of qualitative variables&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 119 melanomas were included&#46; The characteristics of melanomas are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; A total of 29 and 24 melanomas were diagnosed in the 1<span class="elsevierStyleSup">st</span> P19 and 1<span class="elsevierStyleSup">st</span> P20 respectively&#44; and no differences were found in the incidence &#40;16&#46;1 vs&#46; 13&#46;3 per 100&#46;000 inhabitants&#44; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; A total of 36 and 30 melanomas were diagnosed in the 2<span class="elsevierStyleSup">nd</span> P19 and 2<span class="elsevierStyleSup">nd</span> P20 respectively&#44; also without differences in the incidence &#40;20 vs&#46; 16&#46;7 per 100&#46;000 inhabitants&#44; p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patients in both periods were similar in age and sex &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; There were no differences in location&#44; teledermatology referral rate&#44; and presence of ulceration or mitosis &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Invasive melanomas represented 45&#37; and 67&#37; of the diagnosed melanomas in 1<span class="elsevierStyleSup">st</span> P19 and 1<span class="elsevierStyleSup">st</span> P20 respectively&#46; After the recovery of the normal activity&#44; the proportion of invasive melanomas was 58&#37; for 2<span class="elsevierStyleSup">nd</span> P19 and 47&#37; for 2<span class="elsevierStyleSup">nd</span> P20&#46; However&#44; no statistically significant differences in in situ&#47;invasive melanoma rates were found in any of the periods&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Breslow thickness of diagnosed melanomas increased in 2ndP20 in comparison with the previous year &#40;2&#46;4 vs&#46; 1&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; which implied differences in the AJCC stage &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; However&#44; no differences were found in the first period &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Different approaches&#44; such as promoting teledermatology&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> were considered to minimize the effects of COVID-19 on melanoma diagnosis&#46; Valenti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> reported a 2&#46;3-month postponement of revisions of advanced skin cancer&#44; which is similar to the 3-mont average delay that we authors estimated since it took 6-months from the beginning of the lockdown until the normal clinical activity was achieved again&#46; According to some studies&#44; this delay would be enough to observe an upstaging of the invasive melanomas&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> but this increase in Breslow thickness would only be seen once the delay occurred instead of during the lockdown&#46; For this reason&#44; we included a second period after the clinical activity recovered pre-lockdown levels in order to analyze if the diagnosis delay actually had a repercussion in those melanomas that potentially &#8220;stayed at home&#8221;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Some authors found a significant reduction in melanoma diagnosis during the lockdown&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;9</span></a> However&#44; similar to other reports&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> although we found a decrease in the number of melanomas in both periods &#40;5 in the first period and 6 in the second period&#41;&#44; we did not find a significant reduction in the incidence of melanomas per 100&#46;000 inhabitants in any period&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Some reports showed an increase in Breslow thickness or an upstaging of the diagnosed melanomas during the lockdown in comparison with the previous year&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> but since some also showed an important decrease in the number of diagnoses&#44; mainly of in situ melanomas&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> we believe that it would be the outcome of thin melanoma under-diagnosis rather than an &#8220;immediate&#8221; growth of melanomas due to the lockdown&#46; As expected&#44; we did not find differences in Breslow thickness in the first period&#44; but we found a significant increase in Breslow thickness after the recovery of the normal activity compared with the previous year &#40;1&#46;9<span class="elsevierStyleHsp" style=""></span>mm in 2<span class="elsevierStyleSup">nd</span> P19 vs&#46; 2&#46;4<span class="elsevierStyleHsp" style=""></span>mm in 2<span class="elsevierStyleSup">nd</span> P20&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; which implied an upstaging according to the AJCC 8<span class="elsevierStyleSup">th</span> ed&#46; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; This indicates that although we did not find a reduction in the incidence&#44; some melanomas actually suffered a diagnosis delay&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">However&#44; this prognosis worsening found in invasive melanomas due to the deferral seems not to affect in situ melanomas likewise&#46; Coinciding with other reports&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> our results do not show differences in in situ and invasive melanoma rates before and after the beginning of the lockdown&#44; and after the recovery of normal clinical activity &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Therefore&#44; we can assume that a 3-month average diagnosis delay due to COVID-19 did not mean a progression of in situ melanomas in our sample&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">More studies after the normal clinical activity was resumed are required to assess if the diagnosis deferral actually implied an increased progression to invasive melanomas&#46; Although this situation of melanoma diagnosis delay will hopefully not happen again&#44; we believe that it is an exceptional opportunity for the investigation of in situ and invasive melanoma biology&#46; Further investigation in this area could provide valuable information to the melanoma detection protocols and to better understand its natural behavior&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">It was not found a reduction in the incidence of melanomas in any of the considered periods&#46; However&#44; the increase in Breslow thickness and the consequent upstaging observed&#44; once the normal clinical activity was restored&#44; suggests that the COVID-19 lockdown caused a delay in the diagnosis of melanoma and a prognosis worsening of the invasive melanomas&#46; The similar in situ&#47;invasive melanoma rates suggest that a 3-month average diagnosis delay does not necessarily imply an increase in the progression of in situ melanomas&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We believe that it is important to reassess the real repercussion of the lockdown in melanoma by analyzing the melanomas diagnosed once the pre-pandemic clinical activity was restored&#46; The presented results might not be completely generalizable to other regions with different COVID-19 incidences&#46; Therefore&#44; we encourage other authors to analyze mid-term melanoma diagnoses&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Financial support</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Authors&#39; contributions</span><p id="par0085" class="elsevierStylePara elsevierViewall">Pedro Gil-Pallares&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Olalla Figueroa-Silva&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Maria Eugenia Gil-Pallares&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Jos&#233; &#193;ngel V&#225;zquez-Bueno&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Francisca Pi&#241;eyro-Molina&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Benigno Monteagudo&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Cristina De las Heras-Sotos&#58; The study concept and design&#59; data collection&#44; or analysis and interpretation of data&#59; statistical analysis&#59; writing of the manuscript or critical review of important intellectual content&#59; data collection&#44; analysis and interpretation&#59; effective participation in the research guidance&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; final approval of the final version of the manuscript&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 lockdown possibly meant a delay in the diagnosis and treatment of melanoma and therefore&#44; worsening its prognosis&#46; This unique situation of diagnosis deferral is an exceptional opportunity to investigate melanoma biology&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the immediate and mid-term impact of diagnosis delay on melanoma&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A retrospective observational study of melanoma diagnosed between March 14<span class="elsevierStyleSup">th</span> 2019 and March 13<span class="elsevierStyleSup">th</span> 2021&#46; We compared the characteristics of melanomas diagnosed during the first 6-month period after the lockdown instauration and a second period after recovery of normal activity with the same periods of the previous year&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 119 melanomas were diagnosed&#46; There were no differences in age&#44; sex&#44; incidence&#44; location&#44; presence of ulceration or mitoses&#44; and in situ&#47;invasive melanoma rate &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; After the recovery of the normal activity&#44; Breslow thickness increased in comparison with the previous year &#40;2&#46;4 vs 1&#46;9<span class="elsevierStyleHsp" style=""></span>mm&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; resulting in a significant upstaging according to the AJCC 8<span class="elsevierStyleSup">th</span> ed&#46; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Study limitations</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The main limitation is that this is a single-center study&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The COVID-19 lockdown implied a diagnosis delay leading to a mid-term increase in Breslow thickness and an upstaging of invasive melanomas&#46; However&#44; the detection deferral did not result in a higher progression of in situ to invasive melanoma&#44; in our sample&#46;</p></span>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleSup">st</span> Period</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2<span class="elsevierStyleSup">nd</span> Period</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">1<span class="elsevierStyleSup">st</span> P19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">1<span class="elsevierStyleSup">st</span> P20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">2<span class="elsevierStyleSup">nd</span> P19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">2<span class="elsevierStyleSup">nd</span> P20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle"><span class="elsevierStyleBold">Incidence per-100&#46;000 inhabitants</span></td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;583&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;539&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle"><span class="elsevierStyleBold">Age &#40;mean&#41;</span></td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;162&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;974&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Sex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;612&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;48&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;31&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11 &#40;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25 &#40;69&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;63&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Location</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;777&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Head and neck&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;34&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;29&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anterior trunk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Posterior trunk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;31&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;29&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">11 &#40;31&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;27&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Upper extr&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;11&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Lower extr&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acral&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Referral</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;250&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Teledermatology&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold"><span class="elsevierStyleItalic">In situ</span>&#47;invasive</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;166&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;458&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">In situ</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Invasive&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">16 &#40;67&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21 &#40;58&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle"><span class="elsevierStyleBold">Breslow Thickness &#40;mm&#44; mean&#41;</span></td><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="middle"><span class="elsevierStyleBold">Mitoses</span></td><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleBold">pT staging group &#40;AJCC 8<span class="elsevierStyleSup">th</span> ed&#46;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia&#58; a time-series analysis of primary care electronic health records covering about five million people"
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Journal Information
Vol. 98. Issue 2.
Pages 176-180 (1 March 2023)
Visits
4064
Vol. 98. Issue 2.
Pages 176-180 (1 March 2023)
Original Article
Open Access
Did COVID-19 lockdown delay actually worsen melanoma prognosis?
Visits
4064
Pedro Gil-Pallaresa,
Corresponding author
pedrogilpallares@gmail.com

Corresponding author.
, Olalla Figueroa-Silvaa, Maria Eugenia Gil-Pallaresc, José Ángel Vázquez-Buenob, Francisca Piñeyro-Molinaa, Benigno Monteagudoa, Cristina De las Heras-Sotosa
a Department of Dermatology, Complejo Hospitalario Universitario de Ferrol, Ferrol, Spain
b Department of Pathology, Complejo Hospitalario Universitario de Ferrol, Ferrol, Spain
c Universidad de Santiago de Compostela, Santiago de Compostela, Spain
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Abstract
Background

The COVID-19 lockdown possibly meant a delay in the diagnosis and treatment of melanoma and therefore, worsening its prognosis. This unique situation of diagnosis deferral is an exceptional opportunity to investigate melanoma biology.

Objectives

To evaluate the immediate and mid-term impact of diagnosis delay on melanoma.

Methods

A retrospective observational study of melanoma diagnosed between March 14th 2019 and March 13th 2021. We compared the characteristics of melanomas diagnosed during the first 6-month period after the lockdown instauration and a second period after recovery of normal activity with the same periods of the previous year, respectively.

Results

A total of 119 melanomas were diagnosed. There were no differences in age, sex, incidence, location, presence of ulceration or mitoses, and in situ/invasive melanoma rate (p>0.05). After the recovery of the normal activity, Breslow thickness increased in comparison with the previous year (2.4 vs 1.9mm, p<0.05) resulting in a significant upstaging according to the AJCC 8th ed. (p<0.05).

Study limitations

The main limitation is that this is a single-center study.

Conclusions

The COVID-19 lockdown implied a diagnosis delay leading to a mid-term increase in Breslow thickness and an upstaging of invasive melanomas. However, the detection deferral did not result in a higher progression of in situ to invasive melanoma, in our sample.

Keywords:
Melanoma
COVID-19
Prognosis
Quarantine
SARS-CoV-2
Full Text
Introduction

Due to the Coronavirus Disease 2019 (COVID-19) pandemic, many countries went into lockdown, which began in Spain on March 14th 2020.1 Most surgeries and appointments were canceled, and the population was concerned about getting infected. Therefore, patients are mainly consulted for severe symptoms. This could lead to a reduction in the diagnosis of different diseases such as skin cancer,2,3 heart attacks,4 or strokes,5 and a compromise of cancer screening programs.6,7 In the case of melanoma, a recent study estimated an upstaging of 45% of invasive melanomas after a 3-month delay.8

Although some authors noted a reduction in the number of diagnosed melanomas during the lockdown,2,9 other studies showed the opposite results.10,11 However, since most articles limited the studied period to the lockdown it is only possible to estimate the impact of the delay in melanoma diagnosis. We compared the melanomas diagnosed after the lockdown, not only short-term but also once the normal clinical activity was restored, in order to assess if the diagnosis delay due to the COVID-19 lockdown actually meant a prognosis worsening of the melanomas.

Methods

A retrospective, single-center, observational study of histopathologically diagnosed melanomas between March 14th 2019, and March 13th 2021 was designed. This study was approved by the Institutional Ethics Committee. The data was retrieved from the Pathology Department records of our hospital. Demographic data, referral via teledermatology, melanoma location, Breslow thickness (mm), presence of mitosis and ulceration, and AJCC (American Joint Committee on Cancer 8th edition) staging were collected. Incidence was calculated per 100.000 inhabitants. Metastatic melanoma and clinically diagnosed melanoma without histopathological confirmation were excluded. The first 6-month period following the start of the lockdown, between March 14th 2020, and September 13th 2020 (1st P20), and a second 6-month period between September 14th 2020, and March 13th 2021 (2nd P20) were compared with the same periods of the previous year (1st P19 and 2nd P19, respectively).

Statistical analysis was performed using R (R Core Team, Vienna, Austria); t-test and U-Mann Whitney were used for quantitative variables. Fisher’s exact test was used for the analysis of qualitative variables.

Results

A total of 119 melanomas were included. The characteristics of melanomas are summarized in Table 1. A total of 29 and 24 melanomas were diagnosed in the 1st P19 and 1st P20 respectively, and no differences were found in the incidence (16.1 vs. 13.3 per 100.000 inhabitants, p>0.05). A total of 36 and 30 melanomas were diagnosed in the 2nd P19 and 2nd P20 respectively, also without differences in the incidence (20 vs. 16.7 per 100.000 inhabitants, p>0.05).

Table 1.

Patient and tumor characteristics of the melanomas diagnosed between March 14th 2019 and March 13th 2021.

1st Period2nd Period
1st P19  1st P20  p-value  2nd P19  2nd P20  p-value 
n=29  n=24    n=36  n=30   
Incidence per-100.000 inhabitants    0.583      0.539 
16.1  13.3    20  16.7   
Age (mean)    0.162      0.974 
59±18  66±17    70±17  69±16   
Sex          0.612 
Male  14 (48%)  11 (46%)    11 (31%)  11 (37%)   
Female  15 (52%)  13 (54%)    25 (69%)  19 (63%)   
Location      0.777      0.396 
Head and neck  10 (34%)  7 (29%)    12 (33%)  9 (30%)   
Anterior trunk  2 (7%)  4 (17%)    2 (6%)  1 (3%)   
Posterior trunk  9 (31%)  7 (29%)    11 (31%)  8 (27%)   
Upper extr.  6 (21%)  3 (13%)    4 (11%)  2 (7%)   
Lower extr.  2 (7%)  2 (8%)    7 (19%)  6 (20%)   
Acral  1 (4%)    4 (13%)   
Referral      0.250     
Teledermatology  8 (28%)  11 (46%)    10 (28%)  8 (27%)   
In situ/invasive      0.166      0.458 
In situ  16 (55%)  8 (33%)    15 (42%)  16 (53%)   
Invasive  13 (45%)  16 (67%)    21 (58%)  14 (47%)   
Breslow Thickness (mm, mean)    0.263      0.040a 
1.8±1.7  1.2±1.4    1.9±2.7  2.4±2.3   
Ulceration        0.453 
3 (10%)  3 (12%)    3 (8%)  5 (17%)   
Mitoses    0.767      0.310 
8 (28%)  8 (33%)    10 (28%)  12 (40%)   
pT staging group (AJCC 8th ed.)      0.770      0.044a 
pT1a  5 (17%)  9 (38%)    14 (39%)  6 (20%)   
pT1b  1 (3%)  2 (8%)    1 (3%)  1 (3%)   
pT2a  4 (14%)  1 (4%)     
pT2b  1 (3%)  1 (4%)     
pT3a  1 (3%)  1 (4%)    3 (10%)   
pT3b  1 (4%)    2 (7%)   
pT4a    3 (8%)   
pT4b  1 (3%)  1 (4%)    3 (8%)  2 (7%)   

Footnote: 1st P19, March 14th 2019 ‒ September 13th 2019. 1st P20, March 14th 2020 – September 13th 2020. 2nd P19, September 14th 2019 ‒ March 13th 2020. 2nd P20, September 14th 2020 ‒ March 13th 2021.

a

Statistical significance.

The patients in both periods were similar in age and sex (p>0.05). There were no differences in location, teledermatology referral rate, and presence of ulceration or mitosis (p>0.05).

Invasive melanomas represented 45% and 67% of the diagnosed melanomas in 1st P19 and 1st P20 respectively. After the recovery of the normal activity, the proportion of invasive melanomas was 58% for 2nd P19 and 47% for 2nd P20. However, no statistically significant differences in in situ/invasive melanoma rates were found in any of the periods.

Breslow thickness of diagnosed melanomas increased in 2ndP20 in comparison with the previous year (2.4 vs. 1.9mm, p<0.05) which implied differences in the AJCC stage (p<0.05). However, no differences were found in the first period (p>0.05) (Fig. 1).

Figure 1.

Breslow thickness of invasive melanomas did not significantly differ during the first period (p>0.05) (A). However, a statistically significant increase in Breslow thickness was seen in the 2nd P20, after the recovery of normal activity, in comparison with the previous year (p<0.05) (B). These results suggest that some invasive melanomas suffered a diagnosis delay which implied a prognosis worsening.

(0.2MB).
Discussion

Different approaches, such as promoting teledermatology,12 were considered to minimize the effects of COVID-19 on melanoma diagnosis. Valenti et al.13 reported a 2.3-month postponement of revisions of advanced skin cancer, which is similar to the 3-mont average delay that we authors estimated since it took 6-months from the beginning of the lockdown until the normal clinical activity was achieved again. According to some studies, this delay would be enough to observe an upstaging of the invasive melanomas,8 but this increase in Breslow thickness would only be seen once the delay occurred instead of during the lockdown. For this reason, we included a second period after the clinical activity recovered pre-lockdown levels in order to analyze if the diagnosis delay actually had a repercussion in those melanomas that potentially “stayed at home”.

Some authors found a significant reduction in melanoma diagnosis during the lockdown.2,9 However, similar to other reports,10,11 although we found a decrease in the number of melanomas in both periods (5 in the first period and 6 in the second period), we did not find a significant reduction in the incidence of melanomas per 100.000 inhabitants in any period.

Some reports showed an increase in Breslow thickness or an upstaging of the diagnosed melanomas during the lockdown in comparison with the previous year,14,15 but since some also showed an important decrease in the number of diagnoses, mainly of in situ melanomas,15 we believe that it would be the outcome of thin melanoma under-diagnosis rather than an “immediate” growth of melanomas due to the lockdown. As expected, we did not find differences in Breslow thickness in the first period, but we found a significant increase in Breslow thickness after the recovery of the normal activity compared with the previous year (1.9mm in 2nd P19 vs. 2.4mm in 2nd P20, p<0.05) (Fig. 1), which implied an upstaging according to the AJCC 8th ed. (p<0.05). This indicates that although we did not find a reduction in the incidence, some melanomas actually suffered a diagnosis delay.

However, this prognosis worsening found in invasive melanomas due to the deferral seems not to affect in situ melanomas likewise. Coinciding with other reports,10 our results do not show differences in in situ and invasive melanoma rates before and after the beginning of the lockdown, and after the recovery of normal clinical activity (p>0.05). Therefore, we can assume that a 3-month average diagnosis delay due to COVID-19 did not mean a progression of in situ melanomas in our sample.

More studies after the normal clinical activity was resumed are required to assess if the diagnosis deferral actually implied an increased progression to invasive melanomas. Although this situation of melanoma diagnosis delay will hopefully not happen again, we believe that it is an exceptional opportunity for the investigation of in situ and invasive melanoma biology. Further investigation in this area could provide valuable information to the melanoma detection protocols and to better understand its natural behavior.

Conclusions

It was not found a reduction in the incidence of melanomas in any of the considered periods. However, the increase in Breslow thickness and the consequent upstaging observed, once the normal clinical activity was restored, suggests that the COVID-19 lockdown caused a delay in the diagnosis of melanoma and a prognosis worsening of the invasive melanomas. The similar in situ/invasive melanoma rates suggest that a 3-month average diagnosis delay does not necessarily imply an increase in the progression of in situ melanomas.

We believe that it is important to reassess the real repercussion of the lockdown in melanoma by analyzing the melanomas diagnosed once the pre-pandemic clinical activity was restored. The presented results might not be completely generalizable to other regions with different COVID-19 incidences. Therefore, we encourage other authors to analyze mid-term melanoma diagnoses.

Financial support

None declared.

Authors' contributions

Pedro Gil-Pallares: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Olalla Figueroa-Silva: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Maria Eugenia Gil-Pallares: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

José Ángel Vázquez-Bueno: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Francisca Piñeyro-Molina: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Benigno Monteagudo: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Cristina De las Heras-Sotos: The study concept and design; data collection, or analysis and interpretation of data; statistical analysis; writing of the manuscript or critical review of important intellectual content; data collection, analysis and interpretation; effective participation in the research guidance; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; final approval of the final version of the manuscript.

Conflicts of interest

None declared.

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Study conducted at the Department of Dermatology of the Complejo Hospitalario Universitario de Ferrol in Ferrol, A Coruña, Spain.

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