Evaluating potential delays and outcomes of patients undergoing surgical resection for locally advanced and recurrent colorectal cancer during a pandemic

Abstract

Introduction: The COVID-19 pandemic resulted in a significant disruption of colorectal cancer (CRC) care pathways. This study evaluates the management and outcomes of patients with primary locally advanced or recurrent CRC during the pandemic in a single tertiary referral centre.

Methods: Patients undergoing elective surgery for advanced or recurrent CRC with curative intent between March 2020 and March 2021 were identified. Following first multidisciplinary team discussion patients were broadly classified into two groups: straight to surgery (n=22, 45%) or neoadjuvant therapy followed by surgery (n=27, 55%). Primary outcome was COVID-19-related complication rate.

Results: Forty-nine patients with a median age of 66 years (interquartile range: 54-73) were included. No patients developed a COVID-19 infection or related complication during hospital admission. Significant delays were identified in the treatment pathway of patients in the straight to surgery group, mostly due to delays in referral from external centres. Nine of 22 patients in the straight to surgery group had evidence of tumour progression compared with 3 of 27 in the neoadjuvant group (p=0.015839). Seven of 27 patients in the neoadjuvant group showed evidence of tumour regression. During the study, surgical waiting times were reduced, and more operations were performed during the second wave of COVID-19.

Conclusion: This study suggests that it is possible to mitigate the risks of COVID-19-related complications in patients undergoing complex surgery for locally advanced and recurrent CRC. Delay in surgical intervention is associated with tumour progression, particularly in patients who may not have neoadjuvant therapy. Efforts should be made to prioritise resources for patients requiring time-sensitive surgery for advanced and recurrent CRC.

Keywords: Advanced colorectal cancer; COVID-19; Recurrent colorectal cancer; Surgery.

Figure 1

Treatment pathways and breakdown of time intervals in the treatment pathway. (A) Schematic representation of different patient pathways depending on nature of neoadjuvant treatment. (a) Time from diagnosis to first Leeds Teaching Hospitals NHS Trust (LTHT) MDT if diagnosis in our centre, (b) time from diagnosis to first LTHT MDT if patient was referred from an external centre, (c) time from LTHT MDT to surgery for straight to surgery, (d) time from LTHT MDT to neoadjuvant treatment and (e) time from end of neoadjuvant treatment to surgery. (B) Comparison of ideal (light grey) and median actual time intervals (dark grey) during COVID-19 pandemic. The ‘62-day target’ was split to 14 days from diagnosis to MDT and 48 days from MDT to first definitive treatment. The 98-day interval includes 10 weeks of delay after CRT and 4 weeks for imaging, repeat MDT discussion and organisation of surgery. LCRT = long course chemoradiotherapy; LTH = Leeds Teaching Hospitals; NAC = neoadjuvant chemotherapy; NATx = neoadjuvant treatment; SCRT = short course radiotherapy.

Figure 2

Total treatment time and proportions of patients undergoing each treatment strategy. (a) Ideal total treatment time (light grey) and median values of the actual total treatment time during the COVID-19 pandemic (dark grey), calculated from date of diagnosis to date of surgery, for the different treatment pathways. Rationale for ideal time limits: straight to surgery=62-day target. SCRT: 165 days=62 days to treatment+5 days of RT+70 days of delay+28 days to surgery (reimaging, repeat MDT). LCRT: 198 days=62 days to treatment+38 days of RT+70 days of delay+28 days to surgery (reimaging, repeat MDT). No limits are stated for the latter two categories because of variations in applied protocols. (b) Proportion of patients undergoing each treatment strategy. LCRT = long course chemoradiotherapy; NAC = neoadjuvant chemotherapy; SCRT = short course radiotherapy.

Figure 3

Trends of waiting time for surgery during the COVID-19 pandemic. Each dot represents one patient. x axis=date of surgery; left y axis=time interval from decision for operation to date of surgery; right y axis=evolution of the COVID-19 pandemic, indicated by number of COVID-19-positive patients in UK hospitals. The waiting time was reduced, and more patients were operated during the second wave despite the higher numbers of hospitalisations due to COVID-19.