Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study
Academic Article
Publication Date:
2021
Short description:
Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study / Glasbey, J., Ademuyiwa, A., Adisa, A., Alameer, E., Arnaud, A.P., Ayasra, F., Azevedo, J., Minaya-Bravo, A., Costas-Chavarri, A., Elhadi, M., Fiore, M., Fotopoulou, C., Gallo, G., Ghosh, D., Griffiths, E.A., Harrison, E., Hutchinson, P., Lawani, I., Lawday, S., Lederhuber, H., et al.. - In: THE LANCET ONCOLOGY. - ISSN 1474-5488. - 22:11(2021), pp. 1507-1517. [10.1016/S1470-2045(21)00493-9]
abstract:
Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19
outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of
elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.
Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in
61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were
followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19
Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the
period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full
lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not
undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between
lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government
response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.
Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up
of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were
associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted
hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51,
0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate
lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained
independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without
neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in
moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability
rates observed with longer delays.
Interpretation 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 longterm
investment in surge capacity for acute care during public health emergencies to protect elective staff and services.
outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of
elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.
Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in
61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were
followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19
Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the
period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full
lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not
undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between
lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government
response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.
Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up
of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were
associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted
hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51,
0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate
lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained
independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without
neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in
moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability
rates observed with longer delays.
Interpretation 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 longterm
investment in surge capacity for acute care during public health emergencies to protect elective staff and services.
Iris type:
1.1 Articolo in rivista
List of contributors:
Glasbey, J.; Ademuyiwa, A.; Adisa, A.; Alameer, E.; Arnaud, A. P.; Ayasra, F.; Azevedo, J.; Minaya-Bravo, A.; Costas-Chavarri, A.; Elhadi, M.; Fiore, M.; Fotopoulou, C.; Gallo, G.; Ghosh, D.; Griffiths, E. A.; Harrison, E.; Hutchinson, P.; Lawani, I.; Lawday, S.; Lederhuber, H.; Leventoglu, S.; Li, E.; Gomes, G. M. A.; Mann, H.; Marson, E. J.; Martin, J.; Mazingi, D.; Mclean, K.; Modolo, M.; Moore, R.; Morton, D.; Ntirenganya, F.; Pata, F.; Picciochi, M.; Pockney, P.; Ramos-De la Medina, A.; Roberts, K.; Roslani, A. C.; Kottayasamy Seenivasagam, R.; Shaw, R.; Simoes, J. F. F.; Smart, N.; Stewart, G. D.; Sullivan, R.; Sundar, S.; Tabiri, S.; Taylor, E. H.; Vidya, R.; Nepogodiev, D.; Bhangu, A.; Siaw-Acheampong, K.; Benson, R. A.; Bywater, E.; Chaudhry, D.; Dawson, B. E.; Evans, J. P.; Gujjuri, R. R.; Heritage, E.; Jones, C. S.; Kamarajah, S. K.; Khatri, C.; Khaw, R. A.; Keatley, J. M.; Knight, A.; Mann, H. S.; Mclean, K. A.; Mckay, S. C.; Mills, E. C.; Pellino, G.; Tiwari, A.; Simoes, J. F.; Trout, I. M.; Venn, M. L.; Wilkin, R. J.; Smart, N. J.; Moug, S.; Di Saverio, S.; Vallance, A.; Vimalchandran, D.; Evans, R. P.; Townend, P.; Mckay, S.; Isaac, J.; Satoi, S.; Coonar, A. S.; Marchbank, A.; Caruana, E. J.; Layton, G. R.; Patel, A.; Brunelli, A.; Ford, S.; Desai, A.; Gronchi, A.; Almond, M.; Tirotta, F.; Dumitra, S.; Kolias, A.; Price, S. J.; Fountain, D. M.; Jenkinson, M. D.; Marcus, H. J.; Piper, R. J.; Lippa, L.; Servadei, F.; Esene, I.; Freyschlag, C.; Neville, I.; Rosseau, G.; Schaller, K.; Demetriades, A. K.; Robertson, F.; Alamri, A.; Schache, A. G.; Winter, S. C.; Ho, M.; Nankivell, P.; Rey Biel, J.; Batstone, M.; Ganly, I.; Wilkins, A.; Singh, J. K.; Thekinkattil, D.; Leung, E. Y.; Khan, T.; Chiva, L.; Sehouli, J.; Fagotti, A.; Cohen, P.; Gutelkin, M.; Ghebre, R.; Konney, T.; Pareja, R.; Bristow, R.; Dowdy, S.; Shylasree, T. S.; Ng, J.; Fujiwara, K.; Lamb, B.; Narahari, K.; Mcneill, A.; Colquhoun, A.; Mcgrath, J. S.; Bromage, S.; Barod, R.; Kasivisvanathan, V.; Klatte, T.; Abbott, T. E.; Abukhalaf, S.; Adamina, M.; Ademuyiwa, A. O.; Agarwal, A.; Akkulak, M.; Alderson, D.; Alakaloko, F.; Albertsmeier, M.; Alser, O.; Alshaar, M.; Alshryda, S.; Augestad, K. M.; Bankhead-Kendall, B. K.; Barlow, E.; Beard, D.; Blanco-Colino, R.; Brar, A.; Breen, K. A.; Bretherton, C.; Buarque, I. L.; Burke, J.; Chaar, M.; Chakrabortee, S.; Christensen, P. A.; Cox, D.; Cukier, M.; Cunha, M. F.; Davidson, G. H.; Drake, T. M.; Edwards, J. G.; Emile, S.; Farik, S.; Fitzgerald, J. E.; Garmanova, T.; Grecinos, G.; Gruendl, M.; Halkias, C.; Harrison, E. M.; Hisham, I.; Hutchinson, P. J.; Hwang, S.; Isik, A.; Jonker, P.; Kaafarani, H. M.; Keller, D.; Kruijff, S.; Litvin, A.; Loehrer, A.; Loffler, M. W.; Lorena, M. A.; Modolo, M. M.; Major, P.; Mashbari, H. N.; Metallidis, S.; Mohan, H. M.; Moszkowicz, D.; Ng-Kamstra, J. S.; Maimbo, M.; Negoi, I.; Niquen, M.; Olivos, M.; Oussama, K.; Outani, O.; Parreno-Sacdalanm, M. D.; Rivera, C. J. P.; Pinkney, T. D.; van der Plas, W.; Qureshi, A.; Radenkovic, D.; Richards, T.; Rutegard, M.; Segura-Sampedro, J. J.; Santos, I.; Sayyed, R.; Schache, A.; Schnitzbauer, A. A.; Seyi-Olajide, J. O.; Sharma, N.; Shaw, C. A.; Shu, S.; Soreide, K.; Spinelli, A.; Sund, M.; Tsoulfas, G.; van Ramshorst, G. H.; Vimalachandran, D.; Warren, O. J.; Wedderburn, D.; Wright, N.; Eurosurg, ; Booth, L.; Runigamugabo, E.; Barker, M.; Barker, N.; Cooke, S.; Dore, S.; Horwood, N.; Tierney Weir, C.; Dajti, I.; Allemand, C.; Boccalatte, L. A.; Figari, M.; Lamm, M.; Larranaga, J.; Marchitelli, C.; Noll, F.; Odetto, D.; Perrotta, M.; Saadi, J.; Zamora, L.; Ballester, A. M.; Tapper, K. E.; Zeff, N.; Valenzuela, J. I.; Alurralde, C.; Anastasio, J.; Apas Perez de Nucci, A.; Caram, E. L.; Eskinazi, D.; Mendoza, J. P.; Usandivaras, M.; Badra, R.; Esteban, A.; Garcia, J. S.; Garcia, P. M.; Gerchunoff, J. I.; Lucchini, S. M.; Nigra, M. A.; Vargas, L.; Hovhannisyan, T.; Stepanyan, A.; Vasey, C. E.; Watson, E. G. R.; Ip, C.; Kealey, J.; Lim, C. S. H
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