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. 2023 Jan 3;6(1):e2250394.
doi: 10.1001/jamanetworkopen.2022.50394.

Timeliness and Modality of Treatment for New Cancer Diagnoses During the COVID-19 Pandemic in Canada

Rui Fu  1   2   3 , Rinku Sutradhar  1   2 , Qing Li  1 , Timothy P Hanna  4   5 , Kelvin K W Chan  2   6   7 , Jonathan C Irish  2   8 , Natalie Coburn  1   2   7   9 , Julie Hallet  1   2   6   9 , Anna Dare  1   2   9 , Simron Singh  1   2   10 , Ambica Parmar  1   10 , Craig C Earle  1   10 , Lauren Lapointe-Shaw  1   2   10 , Monika K Krzyzanowska  1   2   10 , Antonio Finelli  1   2   9 , Alexander V Louie  11 , Nicole J Look Hong  1   2   9 , Ian J Witterick  3   7   8 , Alyson Mahar  12 , David R Urbach  1   13 , Daniel I McIsaac  1   14 , Danny Enepekides  3 , Jill Tinmouth  1   2   6   7 , Antoine Eskander  1   2   3
Affiliations

Timeliness and Modality of Treatment for New Cancer Diagnoses During the COVID-19 Pandemic in Canada

Rui Fu et al. JAMA Netw Open. .

Abstract

Importance: The impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care.

Objective: To explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment.

Design, setting, and participants: This retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time.

Exposures: Receiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted.

Main outcomes and measures: The main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment.

Results: Among 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy.

Conclusions and relevance: In this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Hallet reported receiving speaking honoraria from Ipsen Biopharmaceuticals Canada, AAA, Bristol Myers Squibb, and Medtronic outside the submitted work. Dr Krzyzanowska reported receiving grants from Eisai, Exelixis, and Eli Lilly and Co; receiving personal fees for attending the advisory boards of Ipsen and Bayer; and consulting with Eli Lilly and Co outside the submitted work. Dr Finelli reported receiving grants from Canadian Institutes of Health Research during the conduct of the study. Dr Louie reported receiving personal fees from AstraZeneca outside the submitted work. Dr Eskander reported receiving research funding from Merck and consulting for Bristol Myers Squibb outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Cumulative Incidence Functions of First Cancer Treatment Received Within 1 Year After Diagnosis by Modality and COVID-19 Pandemic Period
The cumulative incidence function and associated 95% CIs (represented by shaded areas) of each modality of first cancer treatment were estimated by modeling death without receiving any treatment (not plotted) and the receipt of an alternative modality of first treatment as competing risks. Using the Gray test, the cumulative incidence functions differed significantly by COVID-19 period for chemotherapy and radiation (both P < .001) but did not differ for surgery (P = .12).
Figure 2.
Figure 2.. Cancer Type–Specific Subdistribution Hazard Ratios (sHRs) of Receiving Each Modality of First Cancer Treatment by COVID-19 Period
For each modality of cancer treatment, sHRs and associated 95% CIs are reported on a log scale from the multivariable Fine-Gray regression model, where interaction of the pandemic indicator (pandemic vs prepandemic) with cancer type (vs breast cancer) was included. A log(sHR) greater than 0 indicates an increased rate of being first treated by this modality within 1 year after cancer diagnosis in the pandemic relative to prepandemic period. We present each sHR and associated 95% CI in eTable 4 in Supplement 1. Cancer types captured in other are presented in eTable 2 in Supplement 1. CNS indicates central nervous system; HNC, head and neck; HPB, Hepato-pancreatic-biliary.
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