COVID-19 Pandemic Has Exacerbated CRC Surgery Disparities

Patients who are African American appeared to have worse clinical stages of colon and rectal cancer during surgery in 2020.

The number of patients with colon and rectal cancer undergoing surgery has decreased since the COVID-19 pandemic, which has accompanied a higher proportion of patients presenting with advanced disease, according to findings published in the Journal of the American College of Surgeons.

Among 105,517 patients who were assessed for colon (n = 83,128) or rectal (n = 22,389) cancer between 2019 and 2020, investigators reported a reduction in surgical operations of 17.3% during the first year of the COVID-19 pandemic. Specifically, this decrease included a 21.1% decline for rectal cancer surgery and a 16.3% reduction for colon cancer surgery.

For patients with colon cancer who were treated during the pandemic compared with those who received treatment before the pandemic, there was a significantly lower incidence of T1 tumors (35.5% vs 38.2%) and a higher incidence of T4 tumors (19.2% vs 15.7%).

In those with colon cancer, patients who received surgery in 2020 had a significantly higher likelihood of being diagnosed with high-stage tumors (odds ratio [OR], 1.07; 95% CI, 1.00-1.13; P = .039) per multivariate analysis. Additionally, African American race (OR, 1.20; 95% CI, 1.10-1.31; P <.001), Medicaid (OR, 1.27; 95% CI, 1.13-1.29; P <.001), and having no insurance compared with private insurance (OR, 1.32; 95% CI, 1.10-1.57; P = .002) conferred higher risks for having advanced disease. Being older (OR, 0.83; 95% CI, 0.80-0.86; P <.001) and having a Charlson Deyo score of at least 2 (OR, 0.83; 95% CI, 0.75-0.91; P <.001) were determined to be protective factors against advanced disease.

In the rectal cancer population, the rates of clinical T4 cancers significantly increased for patients treated during the pandemic (16.3%) compared with those who received treatment before the pandemic (13.6%; P = .009). A similar rise was reported for clinical N1 or N2 disease (50.3% vs 47.8%; P <.001), which investigators confirmed by pathology stage.

For patients with rectal cancer who underwent surgery during the pandemic, investigators highlighted a significantly increased risk of stage 3 and 4 tumors (OR, 1.08; 95% CI, 1.01-1.16; P = .024). Factors that correlated with worse disease-stage diagnoses included having Medicaid (OR, 1.22; 95% CI, 1.08-1.38; P = .001) and being uninsured (OR, 1.29; 95% CI, 1.06-1.58; P = .013). Additionally, older age (OR, 0.77; 95% CI, 0.74-0.80; P <.001) and a Charlson Deyo score of 2 or higher (OR, 0.72; 95% CI, 0.63-0.82; P <.001) appeared to be protective against an advanced stage diagnosis.

“As the number of studies analyzing the effect of the pandemic on all aspects of medical care grows, the cumulative impact on clinical outcomes has not been fully understood. In cancer care, we are probably still seeing the tip of the iceberg, as the results of delayed screenings, diagnoses, and medical treatments could continue to present their bill in the future years,” Davide Ferrari, MD, visiting research fellow the Mayo Clinic in Rochester, Minnesota, and the general surgery resident at the University of Milan, and coauthors wrote. “Further retrospectives of public policy are needed to review, and report impacts on the healthcare system.”

Investigators retrospectively analyzed data from the National Cancer Database (NCDB) related to adult patients who underwent surgery for colon and rectal cancer between January 2019 and December 2020. Patients were stratified based on whether they received treatment in 2019 before the pandemic or in 2020 during the pandemic. Investigators used a multivariate logistic regression model to assess the relationship between disease stage and socioeconomic variables.

The analysis included an evaluation of time from diagnosis to treatment for both colon and rectal cancer populations. Time to treatment appeared to be significantly shorter for those who underwent surgery before the beginning of the pandemic.

Among patients with colon cancer, there were no significant differences in length of hospital stay following surgery (P = .10) or readmission rates (P = .23) based on whether surgery was given before or during the pandemic. However, a higher proportion of patients during the pandemic underwent robotic surgery compared with those who were treated before the pandemic (23.2% vs 19.7%).

In the rectal cancer population, investigators reported a higher use of robotic surgery approaches in 2020 (41.5%) than before the pandemic (36.9%). In the pre-pandemic and pandemic groups, respectively, the rates of minimally invasive surgery were 34.3% vs 37.7%, and 24.1% vs 25.4% received open surgery.

Reference

Ferrari D, Violante T, Day CN, et al. Unveiling the hidden consequences: the initial impact of COVID-19 on colorectal cancer operation. J Am Coll Surg. Published online March 25, 2024. doi:10.1097/XCS.0000000000001042