key: cord-0930753-4lijntwn authors: Mizuno, Rei; Ganeko, Riki; Takeuchi, Go; Mimura, Kazuya; Nakahara, Hideto; Hashimoto, Kyoichi; Hinami, Junsuke; Shimomatsuya, Takumi; Kubota, Yoshihiro title: The number of obstructive colorectal cancers in Japan has increased during the COVID-19 pandemic: A retrospective single-center cohort study date: 2020-12-02 journal: Ann Med Surg (Lond) DOI: 10.1016/j.amsu.2020.11.087 sha: 822bb7bea1775a27a09382537d32f7f5996a5cf5 doc_id: 930753 cord_uid: 4lijntwn BACKGROUND: The global pandemic of COVID-19 has changed cancer treatment environments. In Japan, cancer screenings were halted and the numbers of endoscopies and surgeries were restricted in some hospitals based on the state of emergency declared. Herein, we investigated the impact of the COVID-19 pandemic on the characteristics of colorectal cancer (CRC) patients in facilities that are on the frontline of both COVID-19 and cancer treatments. PATIENTS AND METHODS: We retrospectively analyzed the cases of all of the CRC patients (n = 123) who underwent surgery at our regional cancer treatment center and tertiary emergency hospital in Japan during a 120-day period ranging from before to after the state of emergency declaration. CRC patients during the corresponding period in the previous year were also examined. RESULTS: Although the number of CRC patients did not show a significant change related to the pandemic, the incidence of obstructive CRCs significantly increased after the pandemic's start. The numbers of outpatients and colonoscopies both decreased, which could have resulted in the decrease of CRC patients detected by cancer screening during the pandemic. The numbers of symptomatic CRC patients and emergency admissions both increased significantly during the pandemic. CONCLUSION: Our findings indicate the possibility that the discovery of CRCs in patients could be delayed due to the halt in screenings caused by the COVID-19 pandemic, resulting in the increase of obstructive CRCs. These results highlight the importance of cancer screening and suggest that the screening system for cancers should be reorganized before future pandemics. The novel coronavirus disease 2019 (COVID-19) which appeared first in Wuhan, 2 China, in November 2019 has spread around the world rapidly [1, 2] . In Japan, the first 3 case of COVID-19 was reported on 15 January 2020, and the number of cases increased 4 beginning in late March [3] . In Japan's Kyoto Prefecture, the number of COVID-19 5 patients began to increase from March 2020. The governor of Kyoto Prefecture declared a 6 state of emergency on April 17, 2020 and urged residents to stay home unless necessary, 7 until the state of emergency was lifted on May 21, 2020. Facing this unprecedented global 8 pandemic, surgical societies and gastroenterological endoscopy societies addressed the 9 general principles of surgical or endoscopic treatments in relation to COVID-19 infection 10 [4] [5] [6] [7] . The use of appropriate triage was recommended, and clinicians were urged to 11 consider the postponement or cancellation of gastrointestinal endoscopies or alternative 12 therapeutic approaches such as neoadjuvant chemotherapy or chemoradiation instead of 13 surgery, if possible, for the prevention of nosocomial infections that could result in the 14 breakdown of medical care. Based on the state of emergency, the cancer treatment 15 environment (including diagnoses and surgical treatments) has changed dramatically in 2020. We thus speculated that the characteristics of CRC patients during the COVID-19 1 pandemic could be affected. 2 Our institution is a regional cancer treatment center and a tertiary emergency 3 hospital in a medical region in Kyoto Prefecture, which has a population of approx. 4 440,000. Our facilities have been on the frontline of both COVID-19 and cancer 5 management during the COVID-19 pandemic, and patients with COVID-19 have thus 6 been transferred to our hospital and treated during the COVID-19 pandemic. 7 We conducted the present study to determine the impact of the COVID-19 pandemic 8 on the characteristics of CRC patients and cancer management in a hospital on the 9 frontline of both COVID-19 and cancer treatment, and to report the lessons learned from 10 the COVID-19 pandemic. 13 14 This retrospective single-center cohort study has been registered in a publicly accessible 15 database: Clinical Trials (UMIN000042211). This research was approved by the 16 institutional review board (Code: 2020-16) and has been reported in line with the 17 STROCSS criteria [9] . All the CRC patients who underwent surgery at our hospital during a 120-day period 19 ranging from before to after the declaration of the state of emergency were included in this 20 study. The CRC patients who underwent surgery during the corresponding period in the 21 previous year were also examined. We divided the observation period into four periods as 22 follows. Period 1: December 18, 2018 to April 16, 2019, Period 2: April 17 to August 14, 23 2020. CRC patients who did not undergo surgical resection or patients out of above 1 periods were excluded. All of the CRC patients underwent preoperative chest computed 2 tomography (CT) and/or a polymerase chain reaction (PCR) test to rule out COVID-19 3 infection. No restriction for surgery was applied during the COVID-19 pandemic with 4 appropriate prevention. 5 The postoperative follow-up of CRC patients were conducted at our hospital according Poisson's test was used to compare the emergency admission rate and the incidence of 2 obstructive CRCs between periods 1-3 and period 4. The Kruskal-Wallis test was used for 3 the comparison of the distance between the residences of patients and our hospital. All 4 statistical analyses were performed using R ver. 3.6.3 (http://r-project.org/). P <0.05 was 5 considered to be a significant difference. The study population was 123 CRC patients who underwent surgeries during the 10 observational periods. Although our hospital has been accepting patients with COVID-19, 11 none of these CRC patients tested positive for COVID-19. Based on the prefecture's state 12 of emergency, healthcare facilities were encouraged to suspend their cancer screenings and 13 screening or diagnostic endoscopies. In fact, the number of outpatients who came to our 14 department and the number of screening or diagnostic colonoscopies performed at our 15 hospital both significantly decreased after the declaration of the state of emergency (Fig. 1) . 16 We thus suspected that the number of CRC patients undergoing colorectal resection would 17 be decreased during the COVID-19 pandemic. Contrary to our expectations, no significant change was observed in the number of 19 CRC patients who underwent surgeries at our hospital. However, the number of patients 20 who needed an emergency admission and that of patients with obstructive CRCs were 21 significantly increased in period 4. The incidence of complete obstruction at our hospital 22 was roughly 15% before the state of emergency, whereas it increased significantly to 39% 23 during the COVID-19 pandemic (p<0.05). The incidence of partial and complete 24 J o u r n a l P r e -p r o o f obstruction was significantly increased to 67% in period 4, whereas it was 19%-42% in 1 the previous three periods. Consequently, the number of patients with CRC at an advanced 2 pathological stage tended to increase in period 4 ( Table 1) . 3 4 3.2. The delays in the detection of CRCs 5 We next investigated the reasons why the number of obstructive CRCs increased during 6 the COVID-19 pandemic, and two possibilities arose. One possibility is that halting the 7 screening could have delayed the detection of CRCs. As shown in Figure 1 , the numbers of 8 outpatients and screening or diagnostic colonoscopies performed at our hospital started to 9 decrease as COVID-19 started to spread in Kyoto Prefecture in March 2020. This tendency 10 continued for a while, and the numbers began to increase again when the state of 11 emergency was lifted on May 21, 2020 (Fig. 1) . We also examined the events contributing 12 to the detection of CRCs, and we observed that in period 4 the number of patients detected 13 by screening dropped to zero, and the number of patients with abdominal symptoms 14 increased significantly (Fig. 2) . 15 Taken together, our results may indicate that the delays in the detection of and hospitals in Japan limited or halted surgeries (including emergency surgeries) to prevent nosocomial infection; we did not restrict surgeries because our hospital is a regional cancer 1 treatment center and a tertiary emergency hospital with adequate medical staff and 2 appropriate prevention against COVID-19. Therefore, patients who would have otherwise 3 been treated at nearby hospitals might have been more likely to come to our hospital. To 4 investigate this possibility, we examined the distances between the patients' residences and 5 our hospital and found that the patients' locations did not show any significant changes 6 from the pre-pandemic scenario (Fig. 3) . This result indicates that the change in patients' 7 location within their medical service area did not strongly affect the increase in the number 8 of obstructive CRCs during the COVID-19 pandemic. The global COVID-19 pandemic has changed the environment for cancer treatment. They demonstrated that 61% of the surgeons were prepared to defer the elective surgeries 23 for CRCs, with 29% willing to defer for ≤8 weeks [18]. In the present study, the number of outpatients and the number of screening or 1 diagnostic colonoscopies performed at our hospital both fell after the declaration of the 2 state of emergency. We thus expected that the number of CRC patients undergoing a 3 colorectal resection at our hospital would be decreased during the COVID-19 pandemic. 4 However, our analyses revealed no significant change in the number of CRC patients. This 5 could be because our hospital is a designated cancer hospital and a tertiary emergency 6 hospital in its medical service area, and no restriction of surgery was applied with 7 appropriate prevention and preoperative testing with chest CT and/or PCR for COVID-19. 8 Although the total number of CRC patients did not show any significant change in Our findings indicate the possibility that the discovery of CRCs in patients who might be saved could be delayed due to the halt in screenings caused by the COVID-19 pandemic, 1 which highlights the importance of cancer screening. A reorganization of the screening 2 system for cancer before future pandemics of unknown infectious disease seems advisable, 3 taking the lessons learned from the COVID-19 pandemic. The Poisson's test was used to compare the emergency admission rate and the incidence of obstructive CRCs between periods 1-3 and period 4. *p<0.05. Poisson's test was used to compare the data in periods 1-3 and those in period 4. *p<0.05. Each dot indicates the distance between a patient's residence and our hospital. • The number of obstructive colorectal cancer (CRC) patients in Japan has increased during the COVID-19 pandemic, whereas the number of total CRC patients did not change in our regional cancer treatment center/tertiary emergency hospital. • During the COVID-19 pandemic in Japan, the number of CRC patients detected by screening dropped to zero, and the number of patients with abdominal symptoms increased significantly. • It is possible that the delays in the detection of CRCs and surgeries due to halted screenings promoted the progression of CRCs. • The screening systems for cancer should be reorganize before a future pandemic of unknown infectious disease. J o u r n a l P r e -p r o o f The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated. All authors must disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. Examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. There are no conflicts of interests. All sources of funding should be declared as an acknowledgement at the end of the text. Authors should declare the role of study sponsors, if any, in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication. If the study sponsors had no such involvement, the authors should so state. 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Attendances and Emergency Admissions statistics, NHS and Independent Sector Organisations in England Reduction in emergency surgery activity during COVID-19 pandemic in three Spanish hospitals Covid-19: A&E visits in England fall by 25% in week after lockdown Impact of the COVID-19 pandemic on urological practice in emergency departments in Italy Conceptualization, Methodology, Validation, Investigation, Data Curation, Writing -Original Draft. Riki Ganeko: Conceptualization, Formal analysis, Writing -Original Draft, Investigation. Go Takeuchi: Writing -Original Draft, Investigation. Kazuya Mimura: Writing -Original Draft, Investigation. Hideto Nakahara: Writing -Original Draft, Investigation. Kyoichi Hashimoto: Writing -Original Draft, Investigation. Junsuke Hinami: Writing -Original Draft, Investigation. Takumi Shimomatsuya: Writing -Original Draft, Investigation, Supervision. 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