Impact of COVID-19 on cancer care pathways in a comprehensive cancer center in northern Italy

Abstract

The COVID-19 pandemic burdened health care systems worldwide. Health services were reorganized with the dual purpose of ensuring the most adequate continuity of care and, simultaneously, the safety of patients and health professionals. The provision of care to patients within cancer care pathways (cCPs) was not touched by such reorganization. We investigated whether the quality of care provided by a local comprehensive cancer center has been maintained using cCP indicators. A retrospective single-cancer center study was conducted on eleven cCPs from 2019 to 2021 by comparing three timeliness indicators, five care indicators and three outcome indicators yearly calculated on incident cases. Comparisons of indicators between 2019 and 2020, and 2019 and 2021, were performed to assess the performance of cCP function during the pandemic. Indicators displayed heterogeneous significant changes attributed to all cCPs over the study period, affecting eight (72%), seven (63%) and ten (91%) out of eleven cCPs in the comparison between 2019 and 2020, 2020 and 2021, and 2019 and 2021, respectively. The most relevant changes were attributed to a negative increase in time-to-treatment surgery-related indicators and to a positive increase in the number of cases discussed by cCP team members. No variations were found attributed to outcome indicators. Significant changes did not account for clinical relevance once discussed by cCP managers and team members. Our experience demonstrated that the CP model constitutes an appropriate tool for providing high levels of quality care, even in the most critical health situations.

Keywords: COVID-19; cancer care; care pathway; pandemic management; quality management.

Figure 1

Panel (A) shows cCP trends with regard to time-to-diagnosis. Pancreatic cCP is given with regard to both types of diagnosis, namely by cytological/histologic report (dark grey line) and computed tomography report (orange line). Lung cCP is given considering both the first outpatient visit (yellow line) and the date of admission (blue line). Liver cCP is given with regard to first and second imaging (black line), the latter used to assess the diagnosis of cancer, and to first imaging and cytological/histologic report (brown line). Panel (B) shows cCP trends with regard to time-to-discussion. Panel (C) shows cCPs trends with regard to time-to-treatment, regardless of the type of treatment. We considered adjuvant (neoadjuvant in case of breast cancer) chemotherapy and surgery for pancreatic, lung, and breast cCP; radiotherapy and surgery for prostate cCP; radiofrequency ablation (RFA)-percutaneous ethanol injection (PEI), trans-arterial chemo-(TACE)-radioembolization (TARE), and surgery for liver cCP; neoadjuvant chemotherapy and adjuvant chemotherapy post-laparotomy for ovarian cCP; finally, radio- and chemotherapy for lymphoma cCP. For colorectal, glioma and thyroid cCPs, surgery was the treatment of reference. Panels (C1) and (C2) show cCP trends with regard to time-to-surgical treatment and non-surgical-treatment, respectively. On the right side of each panel, capital X identifies significant differences and arrows in brackets detail increased (↑) and decreased (↓) differences. Empty boxes identify non-significant results.

Figure 2

Panel (A) shows how admission extension for surgery to surgery varies over the study period. Results are expressed as the mean of days. Ovarian cCP considers both laparotomy and laparoscopic surgery. Panel (B) shows how requests for psychologic support vary over the study period. Results are expressed as the mean of patients supported. Panel (C) shows how requests involving the palliative care unit varies over the study period. Results are expressed as mean of patients taken in charge by the Unit. Panel (D) shows variations in the number of incident cases discussed by the multidisciplinary team. Panel (E) shows the trend of pain detection expressed in percentage over the study period, defined as the ratio between the total number of admission days for surgery in which pain was detected and the total number of admission days among all cCPs. On the right side of each panel, capital X identifies significant differences and arrows in brackets detail increased (↑) and decreased (↓) differences. Empty boxes identify non-significant results.

Figure 3

Panel (A) shows the total number of second surgeries carried out within 30 days the first one. Panel (B) shows the number of deaths within 30 days post-surgery. Panel (C) shows the total number of readmissions 30 days after surgery. On the right side of each panel, capital X identifies significant differences and arrows in brackets detail increased (↑) and decreased (↓) differences. Empty boxes identify non-significant results.

Figure 4

Distribution of indicators accounting for significant changes among individual cCPs.