Impact of COVID-19 on the management of hepatocellular carcinoma in a high-prevalence area

Abstract

Background & aims: Patients affected by hepatocellular carcinoma (HCC) represent a vulnerable population during the COVID-19 pandemic and may suffer from altered allocation of healthcare resources. The aim of this study was to determine the impact of the COVID-19 pandemic on the management of patients with HCC within 6 referral centres in the metropolitan area of Paris, France.

Methods: We performed a multicentre, retrospective, cross-sectional study on the management of patients with HCC during the first 6 weeks of the COVID-19 pandemic (exposed group), compared with the same period in 2019 (unexposed group). We included all patients discussed in multidisciplinary tumour board (MTB) meetings and/or patients undergoing a radiological or surgical programmed procedure during the study period, with curative or palliative intent. Endpoints were the number of patients with a modification in the treatment strategy, or a delay in decision-to-treat.

Results: After screening, n = 670 patients were included (n = 293 exposed to COVID, n = 377 unexposed to COVID). Fewer patients with HCC presented to the MTB in 2020 (p = 0.034) and fewer had a first diagnosis of HCC (n = 104 exposed to COVID, n = 143 unexposed to COVID, p = 0.083). Treatment strategy was modified in 13.1% of patients, with no differences between the 2 periods. Nevertheless, 21.5% vs. 9.5% of patients experienced a treatment delay longer than 1 month in 2020 compared with 2019 (p <0.001). In 2020, 7.1% (21/293) of patients had a diagnosis of an active COVID-19 infection: 11 (52.4%) patients were hospitalised and 4 (19.1%) patients died.

Conclusions: In a metropolitan area highly impacted by the COVID-19 pandemic, we observed fewer patients with HCC, and similar rates of treatment modification, but with a significantly longer treatment delay in 2020 vs. 2019.

Lay summary: During the coronavirus disease 2019 (COVID-19) pandemic era, fewer patients with hepatocellular carcinoma (HCC) presented to the multidisciplinary tumour board, especially with a first diagnosis of HCC. Patients with HCC had a treatment delay that was longer in the COVID-19 period than in 2019.

Keywords: 2019-nCoV; BCLC, Barcelona Clinic Liver Cancer; COVID-19; Cirrhosis; EASL, European Association for the Study of Liver; HCC, hepatocellular carcinoma; Hepatocellular carcinoma; ICU, intensive care unit; IQR, inter-quartile range; IR, interventional radiology; ITT, intention to treat; LR, liver resection; LT, liver transplantation; MELD, model for end-stage liver disease; MTB, multidisciplinary tumour board; Management; NASH, non-alcoholic steatohepatitis; OR, odds ratio; SIRT, selective internal radiation therapy; TACE, transarterial chemoembolisation; aOR, adjusted OR.

Graphical abstract

Fig. 1

Flow chart of patients included in the study. HCC, hepatocellular carcinoma; IR, interventional radiology; LS, liver surgery; MTB, multidisciplinary tumour board.

Fig. 2

Distribution of patients discussed in the MTB. Number of patients presented to the MTB over the same time periods during 2019 and 2020. Each period was split in half (first 3 weeks and second 3 weeks), and the distribution was compared. The numbers of patients with HCC presented to the MTB in 2020 decreased during the pandemic period: (for 2019: 6–26 March, n = 153; 27 March–7 April, n = 151; for 2020: 6–26 March, n = 132; 27 March–7 April, n = 89, Fisher’s exact test, p = 0.034). The number of patients presented to the MTB with a first diagnosis of HCC also decreased: (for 2019: 6–26 March, n = 52; 27 March–7 April, n = 61; for 2020: 6–26 March, n = 49, 27 March–7 April, n = 34, Fisher’s exact test, p = 0.083). MTB, multidisciplinary tumour board.

Fig. 3

Modification of treatment strategy. Difference between the treatment proposed to the MTB and the treatment actually received, during the study periods (13.3%, n = 39 in 2020 vs. 13%, n = 49 in 2019; Fisher’s exact test, p = 0.909). MTB, multidisciplinary tumour board.

Fig. 4

Modification in treatment intent (A) or class (B), between the 2 time periods. Comparison between years was performed using Fisher’s exact test. BSC, best supportive care; CUR, curative; INTERV, interventional treatment; NON-INTERV, non-interventional treatment; PAL, palliative.