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      Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Cancer diagnostics and surgery have been disrupted by the response of healthcare services to the COVID-19 pandemic. Progression of cancers during delay will impact on patient long-term survival.

          Methods

          We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of three months and six months and periods of disruption of one year and two years. Using healthcare resource costing, we contextualise attributable lives saved and life-years gained from cancer surgery to equivalent volumes of COVID-19 hospitalisations.

          Findings

          Per year, 94,912 resections for major cancers result in 80,406 long-term survivors and 1,717,051 life years gained. Per-patient delay of three/six months would cause attributable death of 4,755/10,760 of these individuals with loss of 92,214/208,275 life-years. For cancer surgery, average life-years gained (LYGs) per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of three/six months (an average loss of 0.97/2.19 LYG per patient). Taking into account units of healthcare resource (HCRU), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of three/six months. For 94,912 hospital COVID-19 admissions, there are 482,022 LYGs requiring of 1,052,949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs.

          Interpretation

          Modest delays in surgery for cancer incur significant impact on survival. Delay of three/six months in surgery for incident cancers would mitigate 19%/43% of life-years gained by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59% when considering resource-adjusted life-years gained. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.

          Highlights

          • Lockdown and re-deployment due to the COVID-19 pandemic is causing significant disruption to cancer diagnosis and management.

          • 3-month delay to surgery across all Stage 1-3 cancers is estimated to cause >4,700 attributable deaths per year in England.

          • The impact on life years lost of 3-6 month to surgery for Stage 1-3 disease varies widely between tumour types.

          • Strategic prioritisation of patients for diagnostics and surgery has potential to mitigate deaths attributable to delays.

          • The resource-adjusted benefit in avoiding delay in cancer management compares favourably to admission for COVID-19 infection.

          Related collections

          Most cited references17

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          Is Open Access

          Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study

          Abstract Objective To characterise the clinical features of patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United Kingdom during the growth phase of the first wave of this outbreak who were enrolled in the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study, and to explore risk factors associated with mortality in hospital. Design Prospective observational cohort study with rapid data gathering and near real time analysis. Setting 208 acute care hospitals in England, Wales, and Scotland between 6 February and 19 April 2020. A case report form developed by ISARIC and WHO was used to collect clinical data. A minimal follow-up time of two weeks (to 3 May 2020) allowed most patients to complete their hospital admission. Participants 20 133 hospital inpatients with covid-19. Main outcome measures Admission to critical care (high dependency unit or intensive care unit) and mortality in hospital. Results The median age of patients admitted to hospital with covid-19, or with a diagnosis of covid-19 made in hospital, was 73 years (interquartile range 58-82, range 0-104). More men were admitted than women (men 60%, n=12 068; women 40%, n=8065). The median duration of symptoms before admission was 4 days (interquartile range 1-8). The commonest comorbidities were chronic cardiac disease (31%, 5469/17 702), uncomplicated diabetes (21%, 3650/17 599), non-asthmatic chronic pulmonary disease (18%, 3128/17 634), and chronic kidney disease (16%, 2830/17 506); 23% (4161/18 525) had no reported major comorbidity. Overall, 41% (8199/20 133) of patients were discharged alive, 26% (5165/20 133) died, and 34% (6769/20 133) continued to receive care at the reporting date. 17% (3001/18 183) required admission to high dependency or intensive care units; of these, 28% (826/3001) were discharged alive, 32% (958/3001) died, and 41% (1217/3001) continued to receive care at the reporting date. Of those receiving mechanical ventilation, 17% (276/1658) were discharged alive, 37% (618/1658) died, and 46% (764/1658) remained in hospital. Increasing age, male sex, and comorbidities including chronic cardiac disease, non-asthmatic chronic pulmonary disease, chronic kidney disease, liver disease and obesity were associated with higher mortality in hospital. Conclusions ISARIC WHO CCP-UK is a large prospective cohort study of patients in hospital with covid-19. The study continues to enrol at the time of this report. In study participants, mortality was high, independent risk factors were increasing age, male sex, and chronic comorbidity, including obesity. This study has shown the importance of pandemic preparedness and the need to maintain readiness to launch research studies in response to outbreaks. Study registration ISRCTN66726260.
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            A War on Two Fronts: Cancer Care in the Time of COVID-19

            Initial reports suggest that COVID-19 can be particularly lethal in patients with cancer. This commentary discusses how to balance a delay in cancer diagnosis or treatment against the risk for a potential COVID-19 exposure, mitigate the risks for significant care disruptions associated with social distancing behaviors, and manage the appropriate allocation of limited health care resources in this unprecedented time of health care crisis.
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              • Article: not found

              Time to Surgery and Breast Cancer Survival in the United States.

              Time to surgery (TTS) is of concern to patients and clinicians, but controversy surrounds its effect on breast cancer survival. There remains little national data evaluating the association.
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                Author and article information

                Contributors
                Journal
                Ann Oncol
                Ann. Oncol
                Annals of Oncology
                The Author(s). Published by Elsevier Ltd on behalf of European Society for Medical Oncology.
                0923-7534
                1569-8041
                19 May 2020
                19 May 2020
                Affiliations
                [1 ]Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
                [2 ]National Cancer Registration and Analysis Service, Public Health England, Wellington House, London, UK
                [3 ]Urology Unit, Royal Marsden NHS Foundation Trust, London, UK
                [4 ]Department of Anaesthesia, Perioperative Medicine and Critical Care, Royal Marsden NHS Foundation Trust, London, UK
                [5 ]Division of Cancer Biology, Institute of Cancer Research, London, UK
                [6 ]Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
                [7 ]Department of Microbiology, Royal Marsden NHS Foundation Trust, London, UK
                [8 ]Lung Cancer Unit, Royal Marsden NHS Foundation Trust, London, UK
                [9 ]Skin and Renal Unit, Royal Marsden NHS Foundation Trust, London, UK
                [10 ]Division of Clinical Studies, Institute of Cancer Research, London, UK
                [11 ]Department of Clinical Oncology, Royal Marsden NHS Foundation Trust, London, UK
                [12 ]RM Partners, West London Cancer Alliance, Royal Marsden NHS Foundation Trust, London, UK
                [13 ]Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
                [14 ]Cancer Evolution and Genome Instability Laboratory, The Francis Crick Institute, London, UK
                [15 ]Cancer Evolution and Genome Instability Laboratory, University College London Cancer Institute, London, UK
                [16 ]Department of Clinical Oncology, Imperial College Healthcare NHS Trust, London, UK
                [17 ]Computational Oncology Group, Imperial College London, London, UK
                [18 ]Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, University College London, London, UK
                [19 ]Department of Clinical Genetics, Royal Marsden NHS Foundation Trust, London, UK
                Author notes
                []Corresponding author: Prof. Clare Turnbull clare.turnbull@ 123456icr.ac.uk
                [∗]

                these authors contributed equally to the work.

                Article
                S0923-7534(20)39825-2
                10.1016/j.annonc.2020.05.009
                7237184
                32442581
                1f5b7756-9c6c-4d2e-8355-a99a4e3a625b
                © 2020 The Author(s)

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 6 May 2020
                : 7 May 2020
                : 10 May 2020
                Categories
                Article

                Oncology & Radiotherapy
                oncology,survival,delay,covid-19,diagnostics
                Oncology & Radiotherapy
                oncology, survival, delay, covid-19, diagnostics

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