Delays in surgery for esophageal cancer did not appear to have much impact on patients’ relative survival for early-stage cancer compared with patients who had surgery early, but they did reduce the relative survival rate by almost half for patients with more advanced disease, according to an analysis of the National Cancer Database (NCDB) published by Bajaj et al in the Journal of the American College of Surgeons. The report is one of the earliest studies to examine the impact of an extended 3-month delay in esophagectomy for esophageal cancer.
“Timely care should always be the priority for patients,” said senior study author Chi-Fu Jeffrey Yang, MD, a thoracic surgeon at Massachusetts General Hospital and an Assistant Professor of Surgery at Harvard Medical School. “However, there were times during the COVID-19 pandemic when delays to cancer care occurred. This study, using prepandemic data, helps us understand the impact of the delay to care for patients with different stages of operable esophageal cancer.”
Lead author Simar Singh Bajaj, a student at Harvard and a researcher in the department of surgery at Mass General, added: “When we looked at early vs delayed surgery for patients with stage I cancer, patients in both groups had similar 5-year survival rates. However, for patients with stage II or III disease, delayed surgery was associated with worse survival when compared with early surgery.”
“This finding is especially important as we’re still working toward reintegrating services during the pandemic,” Mr. Bajaj continued. “We’ve seen a lot of delays in care, as hospitals have been overwhelmed with COVID patients.”
About the Study
The researchers extracted pre–COVID-19 pandemic surgical cases for esophageal cancer from the NCDB, a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The NCDB is estimated to include more than 75% of the newly diagnosed esophageal cancer cases in the United States.
The researchers compared survival of patients with stage I disease who had early surgery—within 4 weeks after their diagnosis—vs delayed surgery at 12 to 16 weeks after diagnosis. For patients with stage II/III esophageal cancer, the analysis compared results, after timely chemoradiation up to 4 weeks after diagnosis, of early esophagectomy (9 to 17 weeks after diagnosis) vs delayed surgery (21 to 29 weeks afterward). Propensity-score matching was used to create two comparator subgroups for timing of surgery within each staging group: 134 in each stage I subgroup and 130 in each stage II/III subgroup.
Study Results
The 5-year relative survival rate was similar for patients with stage I disease who had early and delayed surgery: 65% (55.2%–73.2%) and 65.1% (55.6%–73.1%), respectively (P = .50).
The 5-year relative survival rate for patients with stage II/III cancer who had delayed surgery was about 45% worse than those who had early surgery: 22.9% (14.9%–31.8%) vs 41.6% (32.1%–50.8%), respectively (P = .006).
When we looked at early vs delayed surgery for patients with stage I cancer, patients in both groups had similar 5-year survival rates. However, for patients with stage II or III disease, delayed surgery was associated with worse survival when compared with early surgery.— Simar Singh Bajaj
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Prioritize Patients Without Delaying Care
At the start of the COVID-19 pandemic in March 2020, the Centers for Medicare and Medicaid Services announced that “all elective surgeries [and] nonessential medical, surgical, and dental procedures would be delayed during the 2019 Novel Coronavirus (COVID-19) outbreak” to preserve hospital resources to handle the pandemic. Some national medical societies issued triage guidelines for dealing with delays for a host of elective procedures. The American College of Surgeons and the Thoracic Surgery Outcomes Research Network issued early guidance that recommended a 3-month delay of surgery for esophageal cancer in hospitals with resources—intensive-care unit beds, ventilators, hospital staff—stretched thin by the pandemic.
When appointments could be scheduled again, cancer clinicians noticed patients were slow or unlikely to schedule regular cancer screenings. However, research findings are just starting to emerge to determine the impact that all of these delays may have had on patient outcomes, including survival for a variety of cancers.
“As we continue to move out of the COVID pandemic, surgeons are trying to address the backlog of patients with esophageal cancer. The point of this study is to consider how we should reintegrate services in such a way that it prioritizes patients that are most at risk,” Mr. Bajaj said.
That prioritization means patients with stage II/III esophageal cancer should get surgery “as soon as possible,” he said. Although the researchers found no difference in survival for early vs delayed surgery for patients with stage I esophageal cancer, he warned that’s not a valid reason to delay their care.
“This study should not be used to recommend delays in any circumstance—just because for stage I disease we didn’t see that there was an adverse impact to survival when you delayed surgery,” he said. “Esophageal cancer surgery should always be performed as promptly as possible.”
Guidance for Future Response
The findings provide esophageal cancer guidance for responding to future pandemics or COVID surges, Mr. Bajaj said. “Triage is all about prioritizing patients and trying to treat the most vulnerable first in order to give them the best chance of survival,” he said.
Disclosure: For full disclosures of the study authors, visit journals.lww.com/journalacs.
