Background

Surgery is the main modality of cure for solid cancers and was prioritised to continue even during SARS-CoV-2 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during COVID-19 in periods of lockdown versus light restriction.

Method

This international, prospective cohort study enrolled patients with 15 cancer types who had a decision for surgery during the COVID-19 pandemic up to 31st August 2020. Average national Oxford COVID-19 Stringency Index scores were calculated for each patient during the period they were awaiting surgery, classified into light restrictions (index <20), moderate lockdowns (20-60), and full lockdowns (>60). The primary outcome was the non-operation rate (proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation.

Results

From 20,006 patients (466 hospitals, 61 countries), 9.1% did not receive surgery after a minimum of 3-months’ follow up (median:23 weeks, IQR:16 to 30 weeks)  all of whom had a COVID-19 related reason for non-operation. Light restrictions were associated with a 0.6% non-operation rate, moderate lockdowns 5.5% (adjusted hazard ratio:0.81, 95% confidence interval 0.77-0.84, p<0.001), and full lockdowns with a 15.0% rate (HR:0.51, 0.50-0.53). In sensitivity analyses, including adjustment for SARS-COV-2 rates, moderate and full lockdowns remained independently associated with non-operation. Each additional week in lockdown led to a 9% reduction in the likelihood in a patient undergoing their cancer operation. Frail patients, those with advanced cancer, and those in lower-income settings were particularly vulnerable to lockdown effects. Surgery beyond 12-weeks from diagnosis increased during lockdowns (9.1% in light restrictions, 10.4% moderate lockdowns, 23.8% full lockdowns), although there were no observed differences in resectability rates as a consequence of delays.

Conclusion

Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients not undergoing planned surgery and more preoperative delays. Although short term oncological outcomes were not compromised, delays and non-operations are likely to lead to longer-term survival reductions. 

Impact statement

During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which may include ring-fenced surgical units and critical care capacity.