The application of curative surgery as part of cancer treatments was severely impacted by the COVID-19 pandemic and the subsequent lockdowns. A prospective cohort study reported in The Lancet Oncology by the COVIDSurg Collaborative found that substantial proportions of patients did not undergo planned surgery for cancer in regions with moderate or full COVID-19 related lockdowns.
The study included 20,006 patients from hospitals in 61 countries with fifteen cancer types who had planned curative surgery during the COVID-19 pandemic. Patients were followed until surgery or end of follow-up at the end of August 2020. Average national Oxford COVID-19 Stringency Index scores were used to define government response to COVID-19 for each patient during the period of planned surgery as light restrictions, moderate lockdowns, and full lockdowns. The primary outcome measure was nonoperation rate, defined as the proportion of patients who did not undergo planned surgery.
Among the 20,006 patients with planned surgery, 2,003 (10.0%) did not undergo surgery after a median follow-up of 23 weeks (interquartile range = 16-30 weeks), with all having a COVID-19–related reason for the postponement. The more stringent the lockdowns, the fewer patients received curative surgery for their cancer. In regions with full lockdowns 1,775 (15.0%) of 11,827 patients did not undergo planned surgery. Overall, one in seven patients who were in regions with full lockdowns did not undergo planned surgery and experienced longer preoperative delays. On multivariate analysis, moderate lockdowns (HR[95%CI] = 0.81 [0.77–0.84]; p < 0.0001) and full lockdowns (HR[95%CI] = 0.51[0.50–0.53]; p < 0.0001) were independently associated with nonoperation.
Increasing SARS–CoV-2 case notification rates were associated with increasing nonoperation rates. In a sensitivity analysis that included adjustment for SARS–CoV-2 case notification rates, moderate lockdowns (HR[95%CI] = 0.84[0.80–0.88]; P < 0.001), and full lockdowns (HR[95%CI]= 0.57[0.54–0.60]; p < 0.001) remained independently associated with nonoperation.
Among patients not receiving neoadjuvant therapy (n = 16,975, 84.8% of cohort), surgery was performed at > 12 weeks from diagnosis in 374 (9.1%) of 4,521 patients in regions with light restrictions, 317 (10.4%) of 3,646 in regions with moderate lockdowns, and 2,001 (23.8%) of 11,827 in regions with full lockdowns. Longer delays were not associated with differences in resectability rates. No differences in resectability rates were observed according to light restrictions, moderate lockdowns, or full lockdowns among patients with no delay to surgery.
The investigators concluded, “Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.”
COVIDSurg Collaborative. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. Lancet Oncol. 2021;22(11):1507-17.