key: cord-0919843-qtoa95w6 authors: Kempf, Emmanuelle; Priou, Sonia; Lamé, Guillaume; Daniel, Christel; Bellamine, Ali; Sommacale, Daniele; Belkacemi, Yazid; Bey, Romain; Galula, Gilles; Taright, Namik; Tannier, Xavier; Rance, Bastien; Flicoteaux, Rémi; Hemery, François; Audureau, Etienne; Chatellier, Gilles; Tournigand, Christophe title: Impact of two waves of Sars‐Cov2 outbreak on the number, clinical presentation, care trajectories and survival of patients newly referred for a colorectal cancer: A French multicentric cohort study from a large group of university hospitals date: 2022-01-17 journal: Int J Cancer DOI: 10.1002/ijc.33928 sha: d73e51add4568a8253a82c4d1b111591665406a6 doc_id: 919843 cord_uid: qtoa95w6 The SARS‐Cov2 may have impaired care trajectories, patient overall survival (OS), tumor stage at initial presentation for new colorectal cancer (CRC) cases. This study aimed at assessing those indicators before and after the beginning of the pandemic in France. In this retrospective cohort study, we collected prospectively the clinical data of the 11.4 million of patients referred to the Greater Paris University Hospitals (AP‐HP). We identified new CRC cases between 1 January 2018 and 31 December 2020, and compared indicators for 2018‐2019 to 2020. pTNM tumor stage was extracted from postoperative pathology reports for localized colon cancer, and metastatic status was extracted from CT‐scan baseline text reports. Between 2018 and 2020, 3602 and 1083 new colon and rectal cancers were referred to the AP‐HP, respectively. The 1‐year OS rates reached 94%, 93% and 76% for new CRC patients undergoing a resection of the primary tumor, in 2018‐2019, in 2020 without any Sars‐Cov2 infection and in 2020 with a Sars‐Cov2 infection, respectively (HR 3.78, 95% CI 2.1‐7.1). For patients undergoing other kind of anticancer treatment, the percentages are 64%, 66% and 27% (HR 2.1, 95% CI 1.4‐3.3). Tumor stage at initial presentation, emergency level of primary tumor resection, delays between the first multidisciplinary meeting and the first anticancer treatment did not differ over time. The SARS‐Cov2 pandemic has been associated with less newly diagnosed CRC patients and worse 1‐year OS rates attributable to the infection itself rather than to its impact on hospital care delivery or tumor stage at initial presentation. For patients undergoing other kind of anticancer treatment, the percentages are 64%, 66% and 27% (HR 2.1, 95% CI 1. 4-3.3) . Tumor stage at initial presentation, emergency level of primary tumor resection, delays between the first multidisciplinary meeting and the first anticancer treatment did not differ over time. The SARS-Cov2 pandemic has been associated with less newly diagnosed CRC patients and worse 1-year OS rates attributable to the infection itself rather than to its impact on hospital care delivery or tumor stage at initial presentation. What's new? The SARS-CoV-2 pandemic caused reallocation of healthcare resources that led to delays in diagnosis and treatment of cancer. Here, the authors conducted a retrospective cohort to assess how the pandemic affected care trajectories for colorectal cancer (CRC) cases. They assessed overall survival and tumor stage at initial presentation for patients diagnosed between January 2018 and December 2020. The results show a lower overall survival rate for CRC patients diagnosed in 2020, and that decrease is a result of SARS-CoV-2 infection itself rather than lack of access to treatment. Since the start of the Sars-Cov2 pandemic, iterative campaigns of social distancing occurred worldwide to limit the spread of the virus and hospital crowding. Following guidelines from scientific societies, policymakers interrupted national cancer screening programs during the first lockdown in 2020, including those related to colorectal cancer (CRC). 1 Modeling studies anticipate increased mortality but little empirical evidence is available to assess standards of CRC care and patient outcomes during the pandemic. 19, 20 This study aimed at assessing the impact of the Sars-Cov2 pandemic and related public health policies on patient OS, initial tumor stage and hospital care trajectories of new CRC cases, in the Paris region during and after the outbreak of the Sars Cov2 epidemic in early 2020. We conducted a retrospective cohort study using the Greater Paris University Hospitals (AP-HP) Clinical Data Warehouse (CDW) integrating routinely collected medical and administrative data of 11.4 million patients. 24 Tumor stage of the CRC cases is available in patients' unstructured electronic health records (EHRs) only. We estimated the rates of missing text reports (CT scans and pathology) within patients' EHRs which were stable over time (Supplementary Methods and Figures S4 and S5 ). We extracted the pathological tumor stage (according to the AJCC 8th edition) for cases with upfront resection of a primary localized colon cancer. 25 To do so, we developed and implemented a regular expression algorithm on the first related postoperative pathology report within the EHR of each patient. We classified the tumor stage according to the risk of relapse: low and high risk defined as pT0-T4N0 and pTxN1-2, respectively. We extracted the metastatic status of CRC cases at initial presentation from the available imaging text reports within the EHRs of each patient. To that aim, we identified CT-scans between 90 days before and 45 days after the CRC diagnosis date. Among them, staging CT-scans were identified using machine learning algorithms. We developed and implemented another regular expression algorithm to assess the tumor metastatic status on these selected reports. The development (training set) and validation (test set) steps of the implemented algorithms are (Table 1 and Figure S2 ). Figures 1A,B, and S3A The algorithm of pTNM identification resulted in a sensitivity and a positive predictive value of 98% and 96% on the test set computed on the available text reports. patients were operated in a context of "major emergency," "minor emergency" and "no emergency," respectively. This repartition did not appear to differ significantly over time, including during lockdown periods ( Figure 4 ). Among the 2572 CRC cases with a tumor resection (primary or secondary), 2289 (89%) were associated with an MDM report: 1331 cases had at least one MDM report before any therapeutic procedure The carcinogenesis steps of the CRC development are long-term events, and the timeline of social distancing may not be significant compared to the timescale of the natural evolution of CRC, despite evidence suggesting that delays to treatment negatively affect outcomes. 12,32 A case-control study on 10 000 patients showed that a delay reaching up to 1 year between the first CRC-related symptom onset and the initial medical visit did not impair the subsequent patient' CRC-related mortality rates. 33 Other observational published data showed no statistical relationship between delays between diagnosis and treatment of CRC, and patient' clinical outcomes-excluding emergency cases. 34 The pattern of carcinogenesis and metastasis evolution in CRC is also still under debate, some authors arguing for a metastatic stage occurring before any tumor detection. 35 4 Those results should be interpreted in the context of routinely collected medical data with relevant information being missing such as the surgery quality assessment. 46 We included tertiary care centers with high-volume cancer surgeries which is associated with better patients' outcomes. 47 No particular method was implemented to account for missing textual data. Yet, the rates of missing text reports were stable over time. Records were frequently reviewed manually to ensure that the data were complete and that their treatment was reliable, according to existing guidelines. 48 When automated data extraction from free-text records was used, algorithms were carefully validated. Although coding errors may be prevalent, their incidence is unlikely to have changed significantly over the period of study and to have affected the longitudinal analysis of data. 49 to all the data in the study and had final responsibility for the decision to submit for publication. The authors have no conflicts of interest to disclose. The data that support the findings of this study are available on request from the corresponding author. All structured and unstructured data used in the study have been pseudonymized. 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