key: cord-1055893-etrkyiki
authors: Larson, David W.; Abd El Aziz, Mohamed A.; Mandrekar, Jay N.
title: How Many Lives Will Delay of Colon Cancer Surgery Cost During the COVID-19 Pandemic? An Analysis Based on the U.S. National Cancer Database
date: 2020-06-15
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2020.06.006
sha: e2c3e854ed5d8270616cafbb959235652d81df96
doc_id: 1055893
cord_uid: etrkyiki

nan

To the Editor: By May 13 th , 2020, 1,342,594 cases of Coronavirus disease (COVID-19) had been confirmed in the United States (U.S.). (1) Of them, 80,820 (6%) patients had died. 1 This rapid viral spread, unencumbered by an effective treatment or vaccine, required wise healthcare resource utilization decisions. Consequently, many centers throughout the world have decided to delay elective surgeries including those for cancer to avoid healthcare system exhaustion. 2 Surgical management of colon cancers is considered the cornerstone of treatment, especially in early-stage disease. 3, 4 Our team at Mayo Clinic derived results based on the American College of Surgeons National Cancer Database (ACS-NCDB), which concluded that delaying elective surgery for patients with stage I-III colon cancer was independently associated with the decrease in the five-year overall survival. (5) Therefore, we have attempted to place into context the potential impact of delay of surgery for colon cancer patients in the setting of the COVID-19 pandemic.

Within our previous series, 5 30,937 (26%) deaths occurred out of 118,504 colon cancer patients during a five-year follow-up. Delaying the surgical resection for patients with stage I-III colon cancer was associated with an increase in the mortality rate within the five years follow up (25% mortality rate when surgery was performed within one month of diagnosis versus 37% after a four-month delay). This increase in death from cancer was already apparent within the first year (Figure 1 ) highlighting the urgency and impact of our nation's healthcare decisions.

In the U.S. we expect to have 104,610 new cases of colon cancer in 2020 with about 83,688 patients having stage I-III colon cancer. 3 This will result in 20,922 (25%) expected deaths within five years of surgery if performed within 30 days of diagnosis (Figure 1) . Unfortunately, if colon cancer surgery is delayed for more than 4 months, it has the potential to result in the deaths of 30,965 within the same five-year period. This potential tragic outcome may result in an additional loss of 10,043 Americans over five years (Figure 1) . This model may be an underestimate, as some patients may die before ever receiving surgery and are not counted. Moreover, this only represents the human tragedy for colon cancer, as the impact of all cancer would be expected to be much larger. Alternative assumptions according to the period of delay in surgery are presented in Figure 1 .

Therefore, political and healthcare leaders must recognize the potential negative impacts on current patients as they address the pandemic before us. Alternative treatments (chemotherapy, immunotherapy, radiotherapy), a national network that would enable refer patients to have surgery in less impacted cities, and screening patients before surgery must be considered to reduce this potential increase in mortality due to the delay in surgical treatment. Furthermore, patients with cancer represent a more vulnerable population and appear to have a higher rate of severe complications after infection with COVID-19. This dilemma along with many other considerations puts into focus the importance of decision making regarding the optimal choice for this vulnerable population.

Grass To calculate the predicted number of deaths for each delay in surgery period's category, the assumption was given that all patients will have the surgery within this period of time (delay), and the estimated number of deaths was calculated based on the results (percentages) as shown in the figure.

COVID-19)-cases in

COVID-19: Elective Case Triage Guidelines for Surgical Care

Cancer statistics, 2020

NCCN Guidelines Insights: Colon Cancer, Version 2