key: cord-0998098-p8d4ledd
authors: Brugel, Mathias; Carlier, Claire; Essner, Christine; Debreuve‐Theresette, Adeline; Beck, Marie‐Françoise; Merrouche, Yacine; Bouché, Olivier
title: Dramatic Changes in Oncology Care Pathways During the COVID‐19 Pandemic: The French ONCOCARE‐COV Study
date: 2020-11-11
journal: Oncologist
DOI: 10.1002/onco.13578
sha: 4c4a547ae24c3a788f33e8d2df991bd0d9425f41
doc_id: 998098
cord_uid: p8d4ledd

The coronavirus disease 2019 (COVID‐19) pandemic may have affected cancer management. We aimed to evaluate changes in every oncology care pathway essential step, from screening to treatment, during the pandemic. Monthly oncological activity differences between 2019 and 2020 (screening tests, histopathological analyzes, multidisciplinary tumor board meetings (MTBMs), diagnostic announcement procedures (DAPs), and treatments were calculated in two French areas experiencing different pandemic intensity (Reims and Colmar). COVID‐19 has had a dramatic impact in terms of screening (−86% to −100%), diagnosis (−39%), and surgical treatment (−30%). This global decrease in all essential oncology care pathway steps contrasted with the relative stability of chemotherapy (−9%) and radiotherapy use (−16%). Outbreak occurred earlier and with more intensity in Colmar but had a comparable impact in both areas regarding MTMBs and DAPs. The current ONCOCARE‐COV study is still in progress and with a longer follow‐up to analyze postlockdown situation.

The coronavirus disease 2019 (COVID-19) pandemic led to prioritizing emergency care dedicated to infection management. Other conditions, such as cancer management, may have been affected during the sanitary lockdown [1]. Consequences of this "distraction effect" are suspected, but the immediate impact of this pandemic is still unknown [2] . The ONCOCARE-COV study evaluated changes in oncological care pathways during the COVID-19 crisis.

Monthly oncological activity indicators were extracted using electronic files and nation-wide procedure codes Classification commune des actes médicaux (CCAM) from January 1, 2019, to May 31, 2020, in a French area of high COVID-19 incidence (Grand East region), in a tertiary care center (University Hospital and Godinot Cancer Institute in Reims), and in a general hospital (in the first national outbreak epicenter in Colmar). The daily number of infected and deceased inpatients with COVID-19 and the monthly number of different steps of oncological care pathways (screening, diagnosis, multidisciplinary tumor board meeting [MTBM] , diagnosis announcement procedure [DAP] and treatment) were collected (Fig. 1) . We calculated monthly activity differences between 2019 and 2020, focusing on the 3-month COVID-19 pandemic period, to identify changes and to compare DAP and MTBM between both areas (Reims and Colmar). Trends were visually compared using temporal curves. Graphic representation and statistical analyses were performed using R (R Development Core Team, version 1.2.5019) and Excel (Microsoft, version 2018) . This study has been registered on ClinicalTrials.gov (NCT04445870).

Compared with the same trimester in 2019, oncological activity decreased dramatically on all essential oncological care pathway steps during the COVID-19 pandemic. The trends and comparisons of monthly activity volume are depicted in Figures 1 and 2 

Colon and breast cancer screening test fell by 86% to 100%, respectively. All activities linked to sampling, histopathological (−48%), and biomolecular analyses (−69%) were drastically reduced. A decrease in medical announcement consultations (−54%) and oncogeriatric evaluations (−86%) was also observed; fewer medical patient files (−31%; including those of new patients; −39%) were reviewed in MTBM. Regarding treatment, systemic chemotherapy (−9%) and radiotherapy (−16%) experienced a lighter decline, whereas oncological surgical procedures were heavily impacted (−30%) over a 2-month period. All clinical research trials were stopped for 3 months (data not shown), and all hyperthermic intraperitoneal chemotherapies were postponed.

Although the COVID-19 outbreak occurred earlier and with more intensity in Colmar, it had a comparable impact in both areas regarding MTBM and DAP.

COVID-19 has had a dramatic impact on all aspects of the cancer care pathway, particularly in terms of screening, diagnosis, and surgical treatment. To the best of our knowledge, this is the first study assessing the overall management of cancers from screening to treatment. Screening and a drop in the number of screening-related samples were observed in Belgium [3] . Reduction in cancer diagnoses has been noted in other European countries, particularly for colon and skin cancers [4, 5] . Primary care was also impacted, with urgent cancer referrals falling by 60% in the U.K. [6] . We experienced a similar decrease in new oncological referrals. In Spain, outpatient visits decreased, and remote visits using phones or internet became a standard [7] . As in a U.S. tertiary care cancer center (MD Anderson Cancer Center), oncological surgical care was drastically reduced because of limited availability of health personnel, logistical resources, and available beds [8] . Facing this resource scarcity, an international collaborative group recommended a fair and consistent prioritization to maximize health benefits, considering the patient, its disease, and its prognosis [9] . This global decrease in all essential oncology care pathway steps contrasts with the relative stability of chemotherapy and radiotherapy use. Patients anteriorly diagnosed with cancers continued to be treated. Limitations of the present study include lack of information on patient characteristics and prognosis. The consequences of delay in diagnosis and treatment have only been estimated in model-based analysis [10] . Complementary qualitative studies are warranted to estimate the real impact on cancer outcomes. The ongoing CAPANCOVID-19 study aims to evaluate the impact of the COVID-19 pandemic on management and outcomes of patients with exocrine pancreatic cancer (https://clinicaltrials. gov/ct2/show/NCT04406571). The current ONCOCARE-COV study is still in progress, and with a longer follow-up, we The authors wish to thank A. Le Guillou, resident, and C. Barbe, M.D., Ph.D., (both from Reims University Hospital) for providing their assistance in data analysis.

None of these individuals were compensated for their contribution beyond their salaries. The authors also thank D. Pellot, as she helped with the English language revision of the manuscript. Pellot was not compensated for her work. 

Christine Essner: Novartis (C/A-board, treatment of Breast Cancer), Pfizer (ET-formation for agents visiting doctors)

The art of oncology: COVID era

Managing COVID-19 in the oncology clinic and avoiding the distraction effect

The impact of the COVID-19 pandemic and the associated Belgian governmental measures on cancer screening, surgical pathology and cytopathology. Pathobiology 2020

Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands

Cancer diagnostic rates during the 2020 'lockdown

Covid-19: Urgent cancer referrals fall by 60%, showing "brutal" impact of pandemic

Impact of the COVID-19 outbreak on cancer patient flow and management: Experience from a large university hospital in Spain

Flattening the curve in oncologic surgery: Impact of Covid-19 on surgery at tertiary care cancer center

A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: An international collaborative group

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: A modelling study