Fewer patients eligible for sphincter-preserving surgery during pandemic
A study of patients undergoing surgery for rectal cancer at Cleveland Clinic Weston Hospital during the first year of the COVID-19 pandemic found patients presented later and at a more advanced stage and were less likely to be candidates for sphincter-preserving surgery.
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“The dramatic drop in cancer screenings early in the pandemic was a major red flag for the oncology community,” says Steven Wexner, MD, PhD, Director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease & Surgery Center and Chairman of the Department of Colorectal Surgery at Cleveland Clinic Weston Hospital. “We knew patients with malignancies would be adversely affected by early measures directed at social distancing and resource allocation. Now we are seeing the real-world outcomes.”
A recent American Association for Cancer Research report published in February 2022 identified nearly 10 million missed cancer screenings from January through July 2020. It also noted an 11% increase in patients diagnosed with inoperable or metastatic cancer during March 2020 to December 2020 compared with the same period in 2019. In addition, the AACR report documented delays in all cancer treatment modalities.
“It’s clear that the pandemic delayed many cancer screenings and services in the United States, but the full repercussions are not yet known,” says Dr. Wexner, though he points to recent concerns expressed by leaders from the American College of Surgeons Commission on Cancer, the American Cancer Society, and other organizations about the problem of delayed and missed screening examinations. “We wanted to look at immediate impacts on rectal cancer treatment.”
The single-center retrospective study looked at five years of data and included 234 patients undergoing surgery for newly diagnosed rectal cancer. The study group (COVID-19 era) consisted of 54 patients (23%) operated on during the first year of the pandemic (Mar. 2020–Feb. 2021), while the control group (pre-COVID-19) included 180 (77%) patients operated on prior to the pandemic (Mar. 2016–Feb. 2020).
Clinical staging was determined by pelvic MRI using a rectal cancer scan protocol, and individuals with T3 and T4 clinical staging were considered to have locally advanced disease. Patients who presented with liver or lung metastases before surgery and underwent surgery for rectal cancer following a multidisciplinary team consensus decision were also included.
“Our primary outcome measure was the rate of sphincter-preserving operations compared to abdominoperineal resection with a permanent colostomy,” says Dr. Wexner, noting all treatment decisions were based solely upon oncological considerations following current NCCN and ACS CoC NAPRC clinical practice guidelines and standards. Sphincter-preserving operations included transanal local excision and low anterior resection with restorative proctectomy or coloanal anastomosis.
In the study, the COVID-19-era group presented with a significantly higher rate of locally advanced disease, with 79% of patients identified stage T3/T4 versus 58% in the pre-COVID-19 group. Metastatic disease was also higher in the study group (9% vs 3%). In addition, this group showed a significantly lower rate of sphincter-preserving surgery (73% vs 86%) and had a much higher percentage of patients treated with total neoadjuvant therapy (TNT) than the control group (52% vs 15%). TNT incorporates chemotherapy with neoadjuvant chemoradiotherapy (CRT) before surgery and is an alternate treatment strategy for locally advanced rectal cancer.
Time to treatment, measured from diagnosis to initiation of any treatment modality, was significantly prolonged in the COVID-19-era group (11.1 vs 8.7 weeks), as was the median time from diagnosis to surgery (9.5 vs 5 months).
After stratifying patients who underwent TNT protocol treatment, the median time from diagnosis to surgery for patients treated with TNT in the COVID-19-era group also was significantly longer compared to patients treated with TNT in the pre-COVID-19 group (10.5 vs 9 months). However, the time from diagnosis to surgery for patients without TNT in the COVID-19-era group, while longer, was not statistically significant (5.5 vs 4.5 months).
Cleveland Clinic Weston Hospital’s institutional experience showed that pandemic-era delays in screening and diagnosis of rectal cancer resulted in more patients presenting with locally advanced disease. “This finding is consistent with other studies from around the world,” observes Dr. Wexner in a recent JAMA Network Open commentary.
For example, he cites a multicenter comparative cohort study from Italy that reported patients operated on during the first eight months of the pandemic were more likely to be symptomatic and present with advanced stage disease.
“Furthermore, due to the advanced stage of disease, we saw a significant increase in abdominoperineal resection rates for rectal cancer during that period, which unfortunately will adversely impact patient quality of life,” he notes.
The Cleveland Clinic Florida study also showed that time from diagnosis to initiation of any treatment modality for rectal cancer was significantly prolonged in patients operated on during the first year of the pandemic. “While we’ve confirmed patients also experienced treatment delays related to the pandemic, it will take more time and future study to see how these delays impact oncological outcomes and overall survival.”
Colorectal cancer is the second leading cause of cancer death in the United States. Nearly 150,000 new cases are expected to be diagnosed this year, with more than 50,000 colorectal cancer-related deaths. “The healthcare community must collectively and diligently work to assure patients that it is not only safe but essential to be screened,” asserts Dr. Wexner.
“Even before the pandemic, colorectal cancer screening lagged behind other recommended cancer screenings,” he adds. “So, it is not enough to just catch up to old screening rates. We must do better in order to reduce late-stage cancer diagnoses and preventable deaths.”
