Differences in Cancer Treatment Continuity Throughout the COVID-19 Pandemic

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No one would deny that there were various consequences due to the COVID-19 pandemic, including the fact that continuity of care in the cancer space was negatively affected.

Many might remember that due to the rapid spread of the SARS-CoV-2 virus, alongside the rise in US death due to the virus, the Centers for Disease Control and Prevention enacted stay-at-home orders during times when transmission was peaking. During these times, oncology teams had to make modifications of their own in the form of moving to telehealth, delaying various in-person procedures, and rescheduling/delaying cancer screenings, which unfortunately, impacted portions of this population that was at greater risk of experiencing greater COVID complications.

Reports have shown that ethnic and racial minority groups presented more a likelihood of experiencing a poor outcome during the pandemic compared to the non-Hispanic White portion of the population.¹ However, there haven’t been any deeper dives into the factors that have contributed to racial inequities in cancer treatment delays—as a result, a study published in JAMA Network Open sought to explore these aforementioned inequities throughout the course of the pandemic by determining which groups were more likely to experience cancer treatment delays or discontinuations (TDDs).¹

Study investigators collected data from April 2020 to September 2022 from the American Society of Clinical Oncology (ASCO) Survey on COVID-19 in Oncology Registry, which consists of information surrounding COVID treatments and outcomes, along with cancer treatment and outcomes among cancer patients who have been diagnosed with SARS-CoV-2 infection or COVID-19. Racial and ethnic differences were analyzed during five different waves of the COVID pandemic in the United States, based on a surge in cases, including before July 2020; July to November 2020; December 2020 to March 2021; April 2021 to February 2022; and March to September 2022).

A total of 69 practices took part in the ASCO registry, with the breakdown being as follows:

• Sixteen (23%) were academic institutions
• Sixteen (23%) were independent or physician-owned clinics
• Thirty-seven (54%) were health systems or nonacademic hospitals

Location wise, 69 clinics, 22 (32%) were in the Midwest, 12 (17%) in the Northeast, 25 (36%) in the South, and 10 (15%) in the West.

In this study, a TDD was considered any cancer treatment that was either postponed more than two weeks or cancelled with no plan to reschedule. In order to properly quantify TDDs associations, investigators estimated adjusted prevalence ratios with the help of a multivariable Poisson regression model, which considered any nonindependence of patients within clinics, while adjusting for age, body mass index, cancer type, cancer extent, comorbidities, and SARS-CoV-2 severity (severe defined as death, hospitalization, intensive care unit admission, or mechanical ventilation).

Overall, a total of 4,054 patients with cancer and SARS-CoV-2 were included (143 [3.5%] American Indian or Alaska Native, 176 [4.3%] Asian, 517 [12.8%] Black or African American, 469 [11.6%] Hispanic or Latinx, and 2747 [67.8%] White; 2403 [59.3%] female; 1419 [35.1%] aged 50-64 years; 1928 [47.7%] aged ≥65 years).

The analysis focused on patients scheduled (at SARS-CoV-2 diagnosis) to receive drug-based therapy (3682 [90.8%]), radiation therapy (382 [9.4%]), surgery (218 [5.4%]), or transplant (30 [0.7%]), while 1,853 (45.7%) had experienced TDD. Analysis also uncovered that during the pandemic, differences in racial and ethnic inequities based on case surge with overall TDD fell over time. In multivariable analyses, non-Hispanic Black (third wave: aPR, 1.56; 95% CI, 1.31-1.85) and Hispanic or Latinx (third wave: aPR, 1.35; 95% CI, 1.13-1.62) patients experienced a greater likelihood for experiencing TDD compared with non-Hispanic White patients during the first year of the pandemic. By 2022, non-Hispanic Asian patients (aPR, 1.51; 95% CI, 1.08-2.12) were more likely to experience TDD compared with non-Hispanic White patients, and non-Hispanic American Indian or Alaska Native patients were less likely (aPR, 0.37; 95% CI, 0.16-0.89).

As a result, the investigators concluded that, “In this cross-sectional study of patients with cancer and SARS-CoV-2 infection, we observed important racial and ethnic disparities in cancer TDDs throughout different waves of the pandemic, hallmarking the importance of continuing to monitor the potential adverse downstream effects of the pandemic on cancer outcomes in the United States.

“Through this analysis, we provide important insights into the potential long-term impacts of the COVID-19 pandemic on cancer-specific outcomes. In the wake of the pandemic, it is important for oncology clinicians to engage in discussions with their patients, particularly patients from racially and ethnically minoritized communities, to ensure they receive the support they may need in the face of an increasing disproportionate burden of poor cancer outcomes in the coming years. Evaluating the downstream effects of clinician-level decisions on cancer treatment delivery in response to COVID-19 national policies will be an important area of research to delineate any adverse cancer-related outcomes, such as worsened survival.”

Reference

1. Islam JY, Hathaway CA, Hume E, et al. Racial and Ethnic Inequities in Cancer Care Continuity During the COVID-19 Pandemic Among Those With SARS-CoV-2. JAMA Netw Open. 2024;7(5):e2412050. doi:10.1001/jamanetworkopen.2024.12050