COVID-19 pandemic led to shifts in timeliness, modality of initial cancer treatment
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Key findings:
- Adults diagnosed with cancer during the COVID-19 pandemic had a lower likelihood of undergoing surgery as first-line treatment, but a higher likelihood of receiving first-line chemotherapy or radiotherapy.
- Among the 73% of patients who received treatment within 6 months of a cancer diagnosis, mean wait time decreased from 35.1 days to 29.5 days for surgery, from 43.7 days to 38.4 days for chemotherapy and from 55.8 days to 49 days for radiotherapy.
Canadian adults diagnosed with cancer during the COVID-19 pandemic appeared less likely to undergo surgery as first-line treatment and more likely to receive chemotherapy or radiation compared with patients diagnosed before the pandemic.
The findings, published in JAMA Network Open, also showed shorter wait times among those treated within 6 months of cancer diagnosis during the pandemic, researchers noted.
Rationale and methods
Disruptions in cancer care during the COVID-19 pandemic have created concerns about the potential for negative long-term outcomes, according to study background.
“These concerns are accentuated for patients who were newly diagnosed with cancer in the midst of the pandemic as they tried to navigate an overwhelmed system to access their first cancer treatment,” Rui Fu, a PhD candidate in health economics at Institute of Health Policy, Management and Evaluation at University of Toronto, and colleagues wrote. “Shortly after the start of COVID-19, the weekly volume of cancer treatment, including surgery, chemotherapy and radiation therapy, declined given that hospitals urgently diverted resources to create capacity for COVID-19 care.”
Fu and colleagues sought to examine the effect of the pandemic on modalities of and wait times for first-line cancer treatment.
The retrospective, population-based cohort study included 313,499 adults (mean age, 66.4 years; 51% women) in Canada diagnosed with a new cancer between Jan. 3, 2016, and Nov. 7, 2020.
Researchers followed patients from date of diagnosis for 1 year or until death or June 26, 2021, whichever came first, to ensure a minimum of 6-month follow-up.
They used a multivariable competing-risk regression model to assess the association between time to treatment during the prepandemic period (Jan. 3, 2016, to March 14, 2020) and the COVID-19 period (March 15, 2020, to Nov. 7, 2020).
A time-to-event variable describing the number of days from date of diagnosis to date of first cancer treatment — surgery, chemotherapy or radiation — or to being censored served as the main outcome. Wait time from date of diagnosis to date of treatment among those treated within 6 months after diagnosis served as a secondary continuous outcome.
Results
Patients diagnosed during the pandemic period appeared less likely to undergo surgery (subdistribution HR [sHR] = 0.97; 95% CI, 0.95-0.99) as first-line treatment, but more likely to receive first-line chemotherapy (sHR = 1.26; 95% CI, 1.23-1.3) or radiotherapy (sHR = 1.16; 95% CI, 1.13-1.2).
Moreover, patients diagnosed with breast cancer (sHR = 0.83; 95% CI, 0.8-0.86) or gastric cancers (sHR = 0.64; 95% CI, 0.49-0.82) during the pandemic period appeared less likely to undergo surgery than those diagnosed before the pandemic.
Patients diagnosed with breast cancer appeared more likely to receive first-line treatment with chemotherapy (sHR = 1.74; 95% CI, 1.63-1.85), whereas those diagnosed with gastric cancer appeared more likely to receive radiation therapy (sHR = 1.43; 95% CI, 1.2-1.71).
Among the 73% of patients who received treatment within 6 months of a cancer diagnosis, mean wait time decreased from 35.1 days to 29.5 days for surgery, from 43.7 days to 38.4 days for chemotherapy and from 55.8 days to 49 days for radiotherapy.
Limitations of the study included the potential unmeasured confounding bias associated with cancer stage and subsites, and the inability to track whether further shifts in first cancer treatment occurred after the time of the last update of the cancer registry, researchers wrote.
Implications
Future study is needed to assess the relative harms of cancer treatment cancellations or delays, especially of surgery, compared with interventions for patients without cancer, Fu and colleagues wrote. A robust ethical framework exists for these decisions, they noted, but the lack of data on the negative consequences of delaying elective benign surgery makes it difficult to value one procedure vs. the other.
“While these decisions seem to have excellent face validity, extended delays in surgery of all varieties are problematic, particularly when a health care system is unable to ramp up surgical activity during the recovery phase to extend beyond typical volume,” they wrote. “As for nonsurgical modalities, our analysis suggests patients were both more likely to receive them as first cancer treatments and initiated those treatments more expeditiously during the pandemic. While this likely reflects limitations in surgical resources with stringent prioritization strategies, it may also point to an increase in the appropriate receipt of neoadjuvant therapy that the pandemic has paradoxically brought about.”
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