Investigators have uncovered factors contributing to the COVID-19 pandemic’s destabilization of the usual patterns of cancer care, described specific ways that National Cancer Database data models were impacted by the pandemic, and offered guidance to cancer centers across the United States on how to interpret data from 2020 to the present. As reported by Lum et al in JAMA Surgery, the findings also painted a much larger picture of the many disruptions caused by the COVID-19 pandemic outside of the immediate emergency of treating patients with the virus.
Background
More than 1.1 million U.S. individuals have died from the COVID-19 infection, and although pandemic-related restrictions are easing throughout the country, the effects of the COVID-19 pandemic on chronic diseases such as cancer remain largely unknown.
While monitoring real-time data submissions, the American College of Surgeons Cancer Programs—which manages the National Cancer Database alongside the American Cancer Society—noted variances in new cancer diagnoses in the first several months of 2020. These variances marked a significant change from the historically stable data set, which collects information related to more than 1.5 million new cancer cases each year and represents over 70% of all cancer cases in the United States.
“The pandemic really changed our approach to health care in general, but this was especially true for [patients with cancer] who found their care disrupted and for undiagnosed patients who had to delay screening visits,” emphasized lead study author Sharon Lum, MD, MBA, FACS, Professor and Chair of the Department of Surgery at the Loma Linda University School of Medicine. “Many clinicians in the cancer world knew that care for [patients with cancer] was disrupted in many significant ways. But we didn’t really have any solid reporting of that. This research was an attempt to validate and report changes in the trajectory of cancer cases captured by the [National Cancer Database] in the first year of the pandemic,” she added.
Study Methods and Results
In the new study, the investigators reviewed the cases of 4,045,097 patients aged 18 years and older who were diagnosed with cancer and/or received their first line of therapy at a reporting facility—including those that were Commission on Cancer–accredited but excluding Veterans Affairs–affiliated programs—from January 1, 2018 to December 31, 2020.
“Our goal was to inform [individuals] about what was happening at large in the world of cancer—to provide a global look similar to how a GPS system tells you where you are across the globe—so that [cancer] centers could create context around their specific datasets,” explained co–study author Heidi Nelson, MD, FACS, Medical Director of the American College of Surgeons Cancer Programs. “Rather than dive into specific hypotheses about what may have occurred for each type of cancer, we wanted this research to serve as a point of reference and context, because each hypothesis for cancer is different. Each disease is going to have its own series of hypotheses,” she highlighted.
The investigators noted that the new study offered a detailed look into the complexities and variations that occurred in cancer reporting as a result of the COVID-19 pandemic. Among the findings were:
- The COVID-19 pandemic was associated with significant changes in diagnoses across all cancer types in 2020, with a 14.4% overall decline in the number of reported cancer cases in the National Cancer Database compared with 2019 data. The investigators indicated that this decline may represent over 200,000 cancer cases that went undiagnosed and/or untreated at Commission on Cancer facilities.
- These missing cancer cases are expected to appear in 2021 data and beyond, with patients presenting with potentially more advanced stages of cancer.
- Overall, the proportion of patients diagnosed with early-stage cancers decreased from March 2020 to June 2020 and was subsequently followed by an increase in the proportion of those diagnosed with late-stage cancers—peaking in April 2020 and correcting to previous-year levels by July 2020. However, the 2020 stage distributions for specific cancer types varied.
- The study identified differences across sociodemographic data. Overall, the proportion of White patients with cancer significantly increased, while the proportion of Asian or Pacific Islander, Hispanic, Black, and other/unknown patients with cancer significantly decreased. The investigators suggested that certain racial and ethnic groups were less likely to be diagnosed with cancer and/or receive cancer care during the COVID-19 pandemic, potentially exacerbating existing health disparities in cancer treatment.
- Significant disparities were noted between age groups, with incidences of cancer increasing among patients aged 60 to 79 years, and decreases in age of diagnosis noted among younger and older patient cohorts throughout 2020. The investigators revealed that patients aged 59 years and younger and those aged 81 years and older were less likely to be diagnosed with or treated for cancer compared with previous years.
Conclusions
The investigators noted that future studies may be needed to better understand the lasting effects of the COVID-19 pandemic, including how infections from the virus may have impacted or exacerbated chronic diseases, treatment adherence, patient outcomes, and long-term follow-up of the 14.4% of cancer diagnoses that were not treated according to cancer care standards expected of Commission on Cancer–accredited programs.
“My main takeaway is to really look under the hood when using and analyzing [National Cancer Database] data that from here on out will include data from 2020,” Dr. Lum underscored. “Because what you assume is happening may not actually be happening, and you have to really take a deep dive into the treatment variables and particular disease processes to understand how the [COVID-19] pandemic affected cancer care in your program,” she stated.
The investigators explained that future analyses of National Cancer Database data may also reveal more details about the COVID-19 pandemic and provide valuable information to health-care organizations about how to be better prepared for emergencies.
“Particularly in the first 3 months of the [COVID-19] pandemic, health-care resources were significantly diverted and hospitals were overwhelmed. There were so many things we didn’t know that we weren’t prepared for. How could we be?” Dr. Nelson stressed. “But I don’t think we should bury our heads in the sand [about] what happened and not be aware of the negative things that happened to patients besides COVID-19 infections. If anything, these data show us that you didn’t have to [have a] COVID-19 [infection] to suffer during the pandemic,” she concluded.
As a result of the significant variance identified in 2020 cancer data sets compared with prior years, the investigators specified that cancer centers publishing information with 2020 National Cancer Database data include the following disclaimer language in their publications: “This study includes data from the year 2020, the first year of the COVID-19 pandemic. Variability in reporting 2020 cases in the National Cancer Database must be considered when interpreting results.”
Disclosure: For full disclosures of the study authors, visit jamanetwork.com.
