COVID-19 and Melanoma in Veterans Care

During her session, “Melanoma in Veterans and the COVID-19 Pandemic,” presented on the fourth day of the 2023 AAD Annual Meeting, Rebecca Hartman, MD, MPH, shared insights into tailoring melanoma care for veterans.

To start, Dr Hartman went over what defines a veteran. She defined a veteran as an individual who has served in the US military for roughly 24 months and who has received an honorable discharge. She added that currently there are more than 9 million enrollees in the Veterans Health Administration, of which roughly 6 million are active users.

Next, Dr Hartman reviewed the unique exposures veterans face during their military career. First, they are often exposed to intermittent high UV exposures, particularly during young adulthood. During this, they often have limited use of sun protection that is heightened by the lack of awareness when it comes to the risk of skin cancer. Finally, she briefly went over findings that showed a risk in flight exposure, which consisted of a meta-analysis for male pilots and crew. Roughly, 2.38-fold adjusted incidences were found in participants, with 1.87-fold adjusted mortality. Additionally, there are risks for chemical exposure, particularly a 1.70-fold adjusted incidence was found in Operation Ranch Hand Air Force veterans.

Then, she transitioned into melanoma incidences within active-duty military and veterans by presenting data that showed active-duty military typically have a 1.62-fold adjusted incidence rate, of which the highest incidence rate occurred among Air Force members compared with those in the Army (17.8 versus 9.5 per 100,000 person years). Additionally, veterans presented a 1.34-fold crude incidence rate.

When it comes to melanoma prognosis in veterans, Dr Hartman showed that  5-year melanoma specific survival (MSS) data from the Veterans Affairs Cancer Registry (VACR) presented at 87.4%, whereas the Surveillance, Epidemiology, and End Results (SEER) Program was at 91.6%. Comparatively, in 2-year MSS for stage IV (2015–2017), the VACR was at 51.5% compared with SEER Program, which was at 44.8%.

“Survival disparities by race and rurality were commonly seen in SEER but not in VACR,” Dr Hartman added.

Before transitioning into COVID-19 and melanoma, Dr Hartman shared that novel therapeutics have been shown to improve melanoma outcomes in veterans, and that targeted care could prove to be an additional tool to improve outcomes.

Next, Dr Hartman reviewed practice changes when tackling COVID-19 and melanoma. As of spring 2020, the National Comprehensive Cancer Network guidance requires:

• An up to 3-month delay for surgery in T0/1 melanoma
  • An up to 3-month delay in adjuvant treatment for occult nodal disease
  • Clinical nodal disease to undergo neoadjuvant treatment
  • Changes in immunotherapy administration frequency

She also shared some data from an examination of 143 US dermatology practices that consisted of roughly 5 million patients from 13 states. It found that about 43.1% of participants decreased in melanoma diagnoses from March to May 2020 compared with 2019, and that there was still a 9.1% increase in diagnoses from June to August 2020 compared with 2019.

She then went on to share some insights on melanoma from the National Cancer Database (NCDB), which announced that there are worse outcomes in the Northeast, particularly in academic and larger cancer centers. Additionally, with the peak of the COVID-19 pandemic, there was an increased thickness (2.9 vs 2.5 mm mean thickness) among melanomas undergoing sentinel lymph node biopsy (SLNB), as well as advanced stages when diagnosed. She noted that there was still further research needed regarding incidence and long-term outcomes such as mortality at the population level.

Finally, Dr Hartman shared some innovations and tools that are on the horizon for melanoma care such as:

• Mobile teledermoscopy
• Artificial Intelligence tools for telemedicine photos
• Total body photography

“These innovations may help bridge the melanoma care gap during pandemic events, especially in rural or remote communities,” Dr Hartman concluded.

Reference
Hartman R. Melanoma in veterans and the COVID-19 pandemic. Presented at: AAD Annual Meeting; March 17–21, 2023; New Orleans, LA.