Insights from a global snapshot of the change in elective colorectal practice due to the COVID-19 pandemic

Abstract

Background: There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation.

Objective: To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change.

Design: An online survey of colorectal cancer service change globally in May and June 2020.

Participants: Attending or consultant surgeons involved in the care of patients with colorectal cancer.

Main outcome measures: Changes in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region.

Results: 191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need.

Conclusions: The COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.

Fig 1

Low, moderate and high Hospital Bed Stress (A) and Critical Care Bed Stress (B), derived from the COVID-19 Load compared to the hospital and critical care bed capacities respectively. Centers with low hospital or critical care bed capacity and no COVID patients were determined to have a low stress, whereas similarly sized centers caring for <20 patients deemed at moderate stress. Centers with high hospital or critical care bed capacity and greater than 200 COVID patients were determined to have a high stress, whereas similarly sized centers caring for <200 patients deemed at moderate stress.

Fig 2

Box and whiskers plot of the relationship between national mortality rate from COVID-19 and either Hospital Bed Stress (A) or Critical Care Bed Stress (B). Black circles represent outliers and ‘x’ is a jitter plot of the raw data. p = <0.001 for all comparisons between groups.

Fig 3. Violin plots of Change Score against Hospital Bed Stress and Critical Care Bed Stress metrics.

The summary boxes denote the mean +/- standard deviation for each group. The groups are statistically significantly different (p = 0.007 and <0.001 respectively).

Fig 4

Line plot of the Priority Scores for each variable when scheduling a patient for theatre, with the impact of high, moderate and low Hospital Bed Stress (A) and Critical Care Bed Stress (B) compared. Note: Higher score demonstrates a higher priority.