Did the COVID-19 lockdown result in a delay of colorectal cancer presentation and outcomes? A single centre review

The Impact of COVID-19 Pandemic on the Diagnosis, Treatment, and Outcomes of Colorectal Cancer in Singapore

Background and Objectives: During the COVID-19 pandemic, many countries implemented lockdowns and social distancing measures, which may delay the early diagnosis of colorectal cancer (CRC). This study aims to review the impact of the pandemic on the diagnosis and treatment outcomes of CRC. Materials and Methods: Patients who underwent colonoscopy or surgery for CRC were included. The study was divided into the pre-COVID-19 (January 2019-January 2020), early COVID-19 (February-May 2020), recovery (June-December 2020), and heightened alert (January-December 2021) periods. Cox regression was used to model the waiting time to colonoscopy. Multivariable logistic regression identified associations between time periods and incidence of CRC diagnosed. The characteristics and outcomes of the surgical procedures that were performed were compared across the time periods. Results: A total of 18,662 colonoscopies and 1462 surgical procedures were performed in the study period. Compared to the pre-COVID-19 period, there was a longer time to colonoscopy during the recovery (HR: 0.91; 95% CI: 0.87, 0.94) and heightened alert periods (HR: 0.88; 95% CI 0.85, 0.91). The early COVID-19 (OR: 1.36; 95% CI: 1.04, 1.77) and recovery (OR: 1.20; 95% CI: 1.01, 1.43) periods were associated with higher odds of diagnosing CRC. Compared to the pre-COVID-19 period, there was a higher proportion of ASA 4 patients (4.3% vs. 1.3%; p < 0.001) and stage 4 CRC patients (22.2% vs. 16.9%; p = 0.001) that required surgery during the heightened alert period. Similarly, there was a higher proportion of emergency surgeries (22% vs. 13.3%; p = 0.002); diverting stomas (13.5% vs. 10.5%; p = 0.005), and Hartmann's procedures (4.4% vs. 0.4%; p = 0.001) performed during the heightened alert period. Conclusions: The pandemic was associated with a higher proportion of metastatic CRC patients requiring surgery. Healthcare policies should facilitate early cancer screening, diagnosis, and treatment to reduce cancer-related morbidity for future pandemics.

Impact of the Sars-Cov-2 outbreak on the initial clinical presentation of new solid cancer diagnoses: a systematic review and meta-analysis

BACKGROUND

The COVID-19 pandemic might have delayed cancer diagnosis and management. The aim of this systematic review was to compare the initial tumor stage of new cancer diagnoses before and after the pandemic.

METHODS

We systematically reviewed articles that compared the tumor stage of new solid cancer diagnoses before and after the initial pandemic waves. We conducted a random-effects meta-analysis to compare the rate of metastatic tumors and the distribution of stages at diagnosis. Subgroup analyses were performed by primary tumor site and by country.

RESULTS

From 2,013 studies published between January 2020 and April 2022, we included 58 studies with 109,996 patients. The rate of metastatic tumors was higher after the COVID-19 outbreak than before (pooled OR: 1.29 (95% CI, 1.06-1.57), I2: 89% (95% CI, 86-91)). For specific cancers, common ORs reached statistical significance for breast (OR: 1.51 (95% CI 1.07-2.12)) and gynecologic (OR: 1.51 (95% CI 1.04-2.18)) cancers, but not for other cancer types. According to countries, common OR (95% CI) reached statistical significance only for Italy: 1.55 (1.01-2.39) and Spain:1.14 (1.02-1.29). Rates were comparable for stage I-II versus III-IV in studies for which that information was available, and for stages I-II versus stage III in studies that did not include metastatic patients.

CONCLUSIONS

Despite inter-study heterogeneity, our meta-analysis showed a higher rate of metastatic tumors at diagnosis after the pandemic. The burden of social distancing policies might explain those results, as patients may have delayed seeking care.

Socioeconomic factors and colorectal cancer incidence, stage and quality of care in Denmark during the COVID-19 pandemic

AIM

Efforts to control the COVID-19 pandemic might reduce accessibility for diagnostics and treatment of colorectal cancer. A universal public healthcare system may modify the availability of healthcare services. The aim of this study was to investigate changes in the quality of care for patients with colorectal cancer during the COVID-19 pandemic.

METHOD

Nationwide data from the Danish Colorectal Cancer database and Statistics Denmark on the number of new diagnoses, disease and health behaviour measures, socioeconomic measures, clinical quality measures and time to adjuvant chemotherapy were retrieved. Measures during the COVID-19 pandemic in 2020 and the different pandemic periods were compared to the pre-pandemic period.

RESULT

In 2020, 4035 patients were diagnosed with colorectal cancer, compared with 4346 in 2019 and 4496 in 2018. During the pandemic, patients were more likely to have UICC stage I disease (25.0% vs 23.4%; PR=1.07(95% confidence interval: 1.00;1.15)), belonging to the highest income quintile (PR=1.06(0.98;1.14), receive surgery with a curative aim (PR=1.02(1.01;1.03)), and to be operated on by a specialist (PR=1.07(1.06;1.08)), and less likely to be 60-69 years of age (PR=0.93(0.86;1.00)), non-western immigrants (PR=0.93(0.86;1.00)), diagnosed by screening (PR=0.79(0.73;0.86)) and receiving an acute operation (PR=0.77(0.66;0.91)). Furthermore, during the pandemic, 11.4% fewer patients waited 28 days or longer for initiation of adjuvant oncological treatment.

CONCLUSION

Based on nationwide data, we observed no major adverse effect on disease measures or clinical quality in a tax funded health care system. However, small changes in the socioeconomic composition of the patient population were observed.

Influence of COVID-19 Pandemic on Colorectal Cancer Presentation, Management and Outcome during the COVID-19 Pandemic

The aim of the study was to investigate whether the COVID-19 pandemic and related measures had an influence on colorectal cancer (CRC) presentation, management, and outcomes; it was a retrospective monocentric study. CRC patients undergoing surgery during the COVID-19 pandemic (1 March 2020-28 February 2022) (group B) were compared with patients operated on in the previous two years (1 March 2018-29 February 2020) in the same unit (group A). The primary outcome was to investigate whether there were differences in concern regarding the stage at presentation, as a whole and after dividing groups based on cancer location (right colon cancer, left colon cancer, rectal cancer). Secondary outcomes included differences in the number of patients admitted from emergency departments and emergency surgeries between periods, and differences in the postoperative outcomes. A subanalysis within the pandemic group was conducted on the same outcomes, dividing the aforementioned group based on pandemic trends. Two hundred and eighty (280) were operated on during the study period: 147 in group A and 133 in group B. Stage at presentation was similar between groups; however, the subgroups analysis showed that in the pandemic group, the number of early-stage left colon cancer occurrences almost halves, yet not significantly. Emergency department referral was more common in group B (p-value: 0.003); in group B, they also had longer operations and there was a more frequent use of ostomy. No differences in the number of postoperative complications nor in the postoperative outcomes were found. Patients with CRC were more frequently referred through the emergency department during the COVID-19 pandemic and left-sided cancers appear to be generally diagnosed at a more advanced stage. Postoperative outcomes showed that high specialized colorectal units can deliver standard high-level treatment under high-pressure external conditions.

Colorectal Surgery Outcomes in the United States During the COVID-19 Pandemic

INTRODUCTION

The purpose of this study was to assess colorectal surgery outcomes, discharge destination, and readmission in the United States during the COVID-19 pandemic.

METHODS

Adult colorectal surgery patients in the American College of Surgeons National Surgical Quality Improvement Program database (2019-2020) and its colectomy and proctectomy procedure-targeted files were included. The prepandemic time period was defined from April 1, 2019 to December 31, 2019. The pandemic time period was defined from April 1, 2020 to December 31, 2020 in quarterly intervals (Q2 April-June; Q3 July-September; Q4 October-December). Factors associated with morbidity and in-hospital mortality were assessed using multivariable logistic regression.

RESULTS

Among 62,393 patients, 34,810 patients (55.8%) underwent colorectal surgery prepandemic and 27,583 (44.2%) during the pandemic. Patients who had surgery during the pandemic had higher American Society of Anesthesiologists class and presented more frequently with dependent functional status. The proportion of emergent surgeries increased (12.7% prepandemic versus 15.2% pandemic, P < 0.001), with less laparoscopic cases (54.0% versus 51.0%, P < 0.001). Higher rates of morbidity with a greater proportion of discharges to home and lesser proportion of discharges to skilled care facilities were observed with no considerable differences in length of stay or worsening readmission rates. Multivariable analysis demonstrated increased odds of overall and serious morbidity and in-hospital mortality, during Q3 and/or Q4 of the 2020 pandemic.

CONCLUSIONS

Differences in hospital presentation, inpatient care, and discharge disposition of colorectal surgery patients were observed during the COVID-19 pandemic. Pandemic responses should emphasize balancing resource allocation, educating patients and providers on timely medical workup and management, and optimizing discharge coordination pathways.

Determinants of COVID-19 Outcome as Predictors of Delayed Healthcare Services among Adults ≥50 Years during the Pandemic: 2006-2020 Health and Retirement Study

BACKGROUND

The coronavirus disease 19 (COVID-19) was declared a global pandemic on 11 March 2020. To date, a limited number of studies have examined the impact of this pandemic on healthcare-seeking behaviors of older populations. This longitudinal study examined personal characteristics linked to COVID-19 outcomes as predictors of self-reported delayed healthcare services attributed to this pandemic, among U.S. adults, ≥50 years of age.

METHODS

Secondary analyses were performed using cross-sectional data (1413 participants) and longitudinal data (2881 participants) from Health and Retirement Study (HRS) (2006-2018) linked to the 2020 HRS COVID-19 Project (57% female, mean age: 68 years). Demographic, socioeconomic, lifestyle and health characteristics were evaluated in relation to delayed overall, surgical and non-surgical healthcare services ("Since March 2020, was there any time when you needed medical or dental care, but delayed getting it, or did not get it at all?" and "What type of care did you delay") using logistic regression and Ensemble machine learning for cross-sectional data as well as mixed-effects logistic modeling for longitudinal data.

RESULTS

Nearly 32.7% delayed healthcare services, 5.8% delayed surgical services and 31.4% delayed non-surgical services. Being female, having a college degree or higher and 1-unit increase in depression score were key predictors of delayed healthcare services. In fully adjusted logistic models, a history of 1 or 2 cardiovascular and/or metabolic conditions (vs. none) was associated with 60-70% greater odds of delays in non-surgical services, with distinct findings for histories of hypertension, cardiovascular disease, diabetes and stroke. Ensemble machine learning predicted surgical better than overall and non-surgical healthcare delays.

CONCLUSION

Among older adults, sex, education and depressive symptoms are key predictors of delayed healthcare services attributed to the COVID-19 pandemic. Delays in surgical and non-surgical healthcare services may have distinct predictors, with non-surgical delays more frequently observed among individuals with a history of 1 or 2 cardiovascular and/or metabolic conditions.