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Eskander A, Li Q, Hallet J, et al. Access to Cancer Surgery in a Universal Health Care System During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(3):e211104. doi:10.1001/jamanetworkopen.2021.1104
For many cancers, surgery is central to diagnosis and treatment and is the only curative modality. Treatment delay can result in a missed opportunity for cure and can worsen outcomes.1-3 Postponing cancer surgery may cost more lives than can be saved by diverting surgical resources and services to managing coronavirus disease 2019 (COVID-19) infection.1,2 Delays in surgical care and a backlog of new cancer diagnoses will place unprecedented pressures on health care systems, particularly those with a limited ability to increase throughput.4 Data are lacking on the effect of pandemic deferral policies on cancer surgery case volumes and whether specific subgroups have been disproportionately affected. These data are required to inform surgical policies during future waves of the COVID-19 pandemic, ensuring optimal outcomes and equitable care.4 Although sociodemographic factors (such as belonging to a minority racial or ethnic group, having low income, and having a nonrural residence) have been associated with increased COVID-19 infection rates and less access to treatment,5,6 little is known about whether these factors were also associated with access to cancer surgery during the pandemic. Therefore, we sought to quantify the cancer surgical backlog and determine whether there were differences in sociodemographic and hospital characteristics among patients undergoing cancer surgery in the pre– and peri–COVID-19 periods.
This was a population-based retrospective cohort study in Ontario, Canada, that was approved by the Sunnybrook Health Sciences Centre research ethics board. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Informed consent was waived because this was a population-based retrospective study. The weekly volume of a comprehensive and well-defined list of cancer-directed hospital-based surgical procedures was determined using Canadian Institute for Health Information procedure codes between January 7, 2018, and June 27, 2020. Only institutions that provided complete data during this period were included in the study.
Segmented regression models were constructed to quantify (1) the surgical volume trend pre–COVID-19 (January 7, 2018, to March 14, 2020; preperiod slope), (2) the immediate decrease in surgical volume at the start of the pandemic (March 15, 2020; change in intercept), and (3) the surgical volume trend during the peri–COVID-19 period (periperiod slope, March 15 to June 27, 2020). In comparing patient characteristics from the pre–COVID-19 period with the peri–COVID-19 period, a standardized difference of greater than 0.1 was used to indicate a meaningful difference between groups. Statistical analysis was performed using SAS Enterprise Guide 7.15 (SAS Institute).
We included 543 751 patients (mean [SD] age, 56.9 [16.9] years; 332 156 [61.1%] women) from 112 of 120 hospitals (93.3%) eligible for analysis. There was an immediate 60% decrease in the mean surgical volume on March 15, 2020, compared with the mean surgical volume in the pre–COVID-19 period. This decrease was followed by a 6% increase in mean surgical volume each subsequent week. Surgical volumes did not return to pre–COVID-19 numbers by June 27, 2020 (Figure), resulting in 35 671 fewer completed surgical procedures in the peri–COVID-19 period than the pre–COVID-19 period.
There were few sociodemographic differences between the patients who received surgery in the pre– or peri–COVID-19 period (Table). Measures, such as material deprivation, rurality, immigration, and region, did not differ between patients treated in the pre– or peri–COVID-19 period. However, compared with the pre-COVID-19 period, cancer surgery in the peri–COVID-19 period was more often considered urgent (78 263 [15.4%] vs 9365 [27.6%]; standardized difference, 0.30) and performed more frequently at teaching hospitals (360 807 [29.2%] vs 11 628 [34.2%]; standardized difference, 0.11) and in inpatient settings (233 522 [45.8] vs 20 700 [60.9]; standardized difference, 0.31).
An immediate 60% decrease in cancer-directed surgery was associated with measures aimed at creating capacity for COVID-19 admissions. This decrease led to major disruptions in cancer care with a large deficit of completed cases in the peri–COVID-19 period compared with the pre–COVID-19 period. Importantly, in a universal publicly funded health care environment, sociodemographic factors were not associated with receipt of surgery in the early peri–COVID-19 period. This suggests equally equitable access to surgical care for patients treated in the early peri–COVID-19 period compared with the pre–COVID-19 period. This study is limited by the lack of timely access to the provincial cancer registry data, which decreased cancer specificity (due to data lag). However, these cancer-directed procedures, whether specifically performed for cancer or not, provide insight to cancer surgical services. Further work is needed to ensure patients experiencing material deprivation are not disadvantaged as cancer diagnostic services increase. The Canadian universal health care context is uniquely positioned to answer cancer outcome questions with an equity lens during the COVID-19 pandemic.
Accepted for Publication: January 12, 2021.
Published: March 11, 2021. doi:10.1001/jamanetworkopen.2021.1104
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Eskander A et al. JAMA Network Open.
Corresponding Author: Antoine Eskander, MD, ScM, Department of Otolaryngology–Head and Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, M1-102, Toronto, ON M4N 3M5, Canada (firstname.lastname@example.org).
Author Contributions: Drs Eskander and Sutradhar had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Eskander, Hallet, Coburn, Hanna, Irish, Sutradhar.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Eskander, Hallet, Coburn, Irish, Sutradhar.
Critical revision of the manuscript for important intellectual content: Eskander, Li, Hallet, Coburn, Hanna, Sutradhar.
Statistical analysis: Hallet, Coburn, Sutradhar.
Obtained funding: Eskander, Sutradhar.
Administrative, technical, or material support: Eskander, Li, Irish.
Supervision: Eskander, Sutradhar.
Conflict of Interest Disclosures: Dr Eskander reported receiving grants from Merck and personal fees from Bristol-Myers Squibb outside the submitted work. Dr Hallet reported receiving personal fees from Ipsen and the American Automobile Association outside the submitted work. Dr Coburn reported receiving personal fees from AstraZeneca outside the submitted work. Dr Hanna reported receiving grants from Roche outside the submitted work. No other disclosures were reported.
Funding/Support: This work is supported by a Sunnybrook Research Institute and Sunnybrook Foundation coronavirus disease 2019 (COVID-19) Response Grant. This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).
Role of the Funder/Sponsor: Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: This cohort and these data have not been previously reported and are not under consideration for publication elsewhere. The opinions, results, and conclusions reported in this article are those of the authors and are independent from the funding sources. The analyses, conclusions, opinions, and statements reported in this article are those of the authors and do not necessarily reflect those of Cancer Care Ontario (CCO) or Canadian Institute for Health Information (CIHI). No endorsement by ICES, Ontario Health, CCO, MOHLTC, or CIHI is intended or should be inferred.
Additional Contributions: We thank Service Ontario for the use of the Office of the Registrar General for information on deaths. Other members of the Pandemic-Ontario Collaborative in Cancer Research (POCCR) group who contributed to this work in the form of study design, interpretation of the data, review and approval of the manuscript and decision to submit for publication include Anna Dare, MBChB, PhD (Department of Surgery, University of Toronto), Kelvin KW Chan, MD, PhD (Department of Medical Oncology, University of Toronto), Simron Singh, MD, MPH (Department of Medical Oncology, University of Toronto), Ambica Parmar, MD, MSc (Department of Medical Oncology, University of Toronto), Craig C. Earle, MD, MSc (Department of Medical Oncology, University of Toronto), Lauren Lapointe-Shaw, MD, PhD (Department of Medicine, University of Toronto), Monika K. Krzyzanowska, MD, MPH (Department of Medical Oncology, University of Toronto), Alexander V. Louie, MD, PhD (Department of Radiation Oncology, University of Toronto), Nicole Look-Hong, MD, MSc (Department of Surgery, University of Toronto), Ian Witterick, MD, MSc (Department of Otolaryngology–Head and Neck Surgery, University of Toronto), Alyson Mahar, PhD (Department of Community Health Sciences, University of Manitoba), Tony Finelli, MD, MSc (Division of Urology, Department of Surgery, University of Toronto), David Urbach, MD, MSc (Department of Surgery, University of Toronto), Danny Enepekides, MD, MPH (Department of Otolaryngology–Head and Neck Surgery, University of Toronto). None of the contributors were compensated for their time.
Additional Information: All databases were linked using unique encoded identifiers and analyzed at ICES. Part of this material is based on data and information provided by Ontario Health, CCO, the Ontario Cancer Registry, and CIHI.
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