Association between the COVID-19 pandemic and first cancer treatment modality: a population-based cohort study.

BACKGROUND: Physicians were directed to prioritize using nonsurgical cancer treatment at the beginning of the COVID-19 pandemic. We sought to quantify the impact of this policy on the modality of first cancer treatment (surgery, chemotherapy, radiotherapy or no treatment). METHODS: In this population-based study using Ontario data from linked administrative databases, we identified adults diagnosed with cancer from January 2016 to November 2020 and their first cancer treatment received within 1 year postdiagnosis. Segmented Poisson regressions were applied to each modality to estimate the change in mean 1-year recipient volume per thousand patients (rate) at the start of the pandemic (the week of Mar. 15, 2020) and change in the weekly trend in rate during the pandemic (Mar. 15, 2020, to Nov. 7, 2020) relative to before the pandemic (Jan. 3, 2016, to Mar. 14, 2020). RESULTS: We included 321 535 people diagnosed with cancer. During the first week of the COVID-19 pandemic, the mean rate of receiving upfront surgery over the next year declined by 9% (rate ratio 0.91, 95% confidence interval [CI] 0.88-0.95), and chemotherapy and radiotherapy rates rose by 30% (rate ratio 1.30, 95% CI 1.23-1.36) and 13% (rate ratio 1.13, 95% CI 1.07-1.19), respectively. Subsequently, the 1-year rate of upfront surgery increased at 0.4% for each week (rate ratio 1.004, 95% CI 1.002-1.006), and chemotherapy and radiotherapy rates decreased by 0.9% (rate ratio 0.991, 95% CI 0.989-0.994) and 0.4% (rate ratio 0.996, 95% CI 0.994-0.998), respectively, per week. Rates of each modality resumed to prepandemic levels at 24-31 weeks into the pandemic. INTERPRETATION: An immediate and sustained increase in use of nonsurgical therapy as the first cancer treatment occurred during the first 8 months of the COVID-19 pandemic in Ontario. Further research is needed to understand the consequences.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Early survival for patients newly diagnosed with cancer during COVID-19 in Ontario, Canada: A population-based cohort study.

BACKGROUND: Little is known about the association between the COVID-19 pandemic and early survival among newly diagnosed cancer patients. METHODS: This retrospective population-based cohort study used linked administrative datasets from Ontario, Canada. Adults (≥18 years) who received a cancer diagnosis between March 15 and December 31, 2020, were included in a pandemic cohort, while those diagnosed during the same dates in 2018/2019 were included in a pre-pandemic cohort. All patients were followed for one full year after the date of diagnosis. Cox proportional hazards regression models were used to assess survival in relation to the pandemic, patient characteristics at diagnosis, and the modality of first cancer treatment as a time-varying covariate. Interaction terms were explored to measure the pandemic association with survival for each cancer type. RESULTS: Among 179,746 patients, 53,387 (29.7%) were in the pandemic cohort and 37,741 (21.0%) died over the first post-diagnosis year. No association between the pandemic and survival was found when adjusting for patient characteristics at diagnosis (HR 0.99 [95% CI 0.96-1.01]), while marginally better survival was found for the pandemic cohort when the modality of treatment was additionally considered (HR 0.97 [95% CI 0.95-0.99]). When examining each cancer type, only a new melanoma diagnosis was associated with a worse survival in the pandemic cohort (HR 1.25 [95% CI 1.05-1.49]). CONCLUSIONS: Among patients able to receive a cancer diagnosis during the pandemic, one-year overall survival was not different than those diagnosed in the previous 2 years. This study highlights the complex nature of the COVID-19 pandemic impact on cancer care.

Imaging and physician visits at cancer diagnosis: COVID -19 pandemic impact on cancer care.

BACKGROUND: Little is known about the COVID-19 pandemic impact on the provision of diagnostic imaging and physician visits at cancer diagnosis. METHODS: We used administrative databases from Ontario, Canada, to identify MRI/CT/ultrasound scans and in-person/virtual physician visits conducted with cancer patients within 91 days around the date of diagnosis in 2016-2020. In separate segmented regression procedures, we assessed the trends in weekly volume of these services per thousand cancer patients in prepandemic (June 26, 2016 to March 14, 2020), the change in mean volume at the start of the pandemic, and the additional change in weekly volume during the pandemic (March 15, 2020, to September 26, 2020). RESULTS: Totally, 403,561 cancer patients were included. On March 15, 2020 (COVID-19 arrived), mean scan volume decreased by 12.3% (95% CI: 6.4%-17.9%) where ultrasound decreased the most by 31.8% (95% CI: 23.9%-37.0%). Afterward, the volume of all scans increased further by 1.6% per week (95% CI: 1.3%-2.0%), where ultrasound increased the fastest by 2.4% (95% CI: 1.8%-2.9%). Mean in-person visits dropped by 47.4% when COVID-19 started (95% CI: 41.6%-52.6%) while virtual visits rose by 55.15-fold (95% CI: 4927%-6173%). In the pandemic (until September 26, 2020), in-person visits increased each week by 2.6% (95% CI: 2.0%-3.2%), but no change was observed for virtual visits (p -value = 0.10). CONCLUSIONS: Provision of diagnostic imaging and virtual visits at cancer diagnosis has been increasing since the start of COVID-19 and has exceeded prepandemic utilization levels. Future work should monitor the impact of these shifts on quality of delivered care.

Incident Cancer Detection During the COVID-19 Pandemic.

BACKGROUND: Resource restrictions were established in many jurisdictions to maintain health system capacity during the COVID-19 pandemic. Disrupted healthcare access likely impacted early cancer detection. The objective of this study was to assess the impact of the pandemic on weekly reported cancer incidence. PATIENTS AND METHODS: This was a population-based study involving individuals diagnosed with cancer from September 25, 2016, to September 26, 2020, in Ontario, Canada. Weekly cancer incidence counts were examined using segmented negative binomial regression models. The weekly estimated backlog during the pandemic was calculated by subtracting the observed volume from the projected/expected volume in that week. RESULTS: The cohort consisted of 358,487 adult patients with cancer. At the start of the pandemic, there was an immediate 34.3% decline in the estimated mean cancer incidence volume (relative rate, 0.66; 95% CI, 0.57-0.75), followed by a 1% increase in cancer incidence volume in each subsequent week (relative rate, 1.009; 95% CI, 1.001-1.017). Similar trends were found for both screening and nonscreening cancers. The largest immediate declines were seen for melanoma and cervical, endocrinologic, and prostate cancers. For hepatobiliary and lung cancers, there continued to be a weekly decline in incidence during the COVID-19 period. Between March 15 and September 26, 2020, 12,601 fewer individuals were diagnosed with cancer, with an estimated weekly backlog of 450. CONCLUSIONS: We estimate that there is a large volume of undetected cancer cases related to the COVID-19 pandemic. Incidence rates have not yet returned to prepandemic levels.

Timeliness and Modality of Treatment for New Cancer Diagnoses During the COVID-19 Pandemic in Canada.

Importance: The impact of COVID-19 on the modality and timeliness of first-line cancer treatment is unclear yet critical to the planning of subsequent care. Objective: To explore the association of the COVID-19 pandemic with modalities of and wait times for first cancer treatment. Design, Setting, and Participants: This retrospective population-based cohort study using administrative data was conducted in Ontario, Canada, among adults newly diagnosed with cancer between January 3, 2016, and November 7, 2020. Participants were followed up from date of diagnosis for 1 year, until death, or until June 26, 2021, whichever occurred first, to ensure a minimum of 6-month follow-up time. Exposures: Receiving a cancer diagnosis in the pandemic vs prepandemic period, using March 15, 2020, the date when elective hospital procedures were halted. Main Outcomes and Measures: The main outcome was a time-to-event variable describing number of days from date of diagnosis to date of receiving first cancer treatment (surgery, chemotherapy, or radiation) or to being censored. For each treatment modality, a multivariable competing-risk regression model was used to assess the association between time to treatment and COVID-19 period. A secondary continuous outcome was defined for patients who were treated 6 months after diagnosis as the waiting time from date of diagnosis to date of treatment. Results: Among 313 499 patients, the mean (SD) age was 66.4 (14.1) years and 153 679 (49.0%) were male patients. Those who were diagnosed during the pandemic were less likely to receive surgery first (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99) but were more likely to receive chemotherapy (sHR, 1.26; 95% CI, 1.23-1.30) or radiotherapy (sHR, 1.16; 95% CI, 1.13-1.20) first. Among patients who received treatment within 6 months from diagnosis (228 755 [73.0%]), their mean (SD) waiting time decreased from 35.1 (37.2) days to 29.5 (33.6) days for surgery, from 43.7 (34.1) days to 38.4 (30.6) days for chemotherapy, and from 55.8 (41.8) days to 49.0 (40.1) days for radiotherapy. Conclusions and Relevance: In this cohort study, the pandemic was significantly associated with greater use of nonsurgical therapy as initial cancer treatment. Wait times were shorter in the pandemic period for those treated within 6 months of diagnosis. Future work needs to examine how these changes may have affected patient outcomes to inform future pandemic guideline development.

Characterizing the Impact of Procedure Funding on the Covid-19 Generated Procedure Gap in Ontario: A Population-Based Analysis.

BACKGROUND: Surgical procedures in Canada were historically funded through global hospital budgets. Activity-based funding models were developed to improve access, equity, timeliness and value of care for priority areas. COVID-19 upended health priorities and resulted in unprecedented disruptions to surgical care which created a significant procedure gap. We hypothesized that activity-based funding models influenced the magnitude and trajectory of this procedure gap. METHODS: Population-based analysis of procedure rates comparing pandemic (March 1, 2020 to December 31, 2021) to a pre-pandemic baseline (January 1, 2017 to February 29, 2020) in Ontario, Canada. Poisson generalized estimating equation models were used to predict expected rates in the pandemic based on the pre-pandemic baseline. Analyses were stratified by procedure type (out-patient, in-patient), body region, and funding category (activity-based funding programs vs. global budget). RESULTS: 281,328 fewer scheduled procedures were performed during the COVID-19 period compared to the pre-pandemic baseline (Rate Ratio 0.78; 95%CI 0.77-0.80). In-patient procedures saw a larger reduction (24.8%) in volume compared to out-patient procedures (20.5%). An increase in the proportion of procedures funded through activity-based programs was seen during the pandemic (52%) relative to the pre-pandemic baseline (50%). Body systems funded predominantly through global hospital budgets (e.g. gynecology, otologic surgery) saw the least months at or above baseline volumes whereas those with multiple activity-based funding options (e.g. musculoskeletal, abdominal) saw the most months at or above baseline volumes. CONCLUSIONS: Those needing procedures funded though global hospital budgets may have been disproportionately disadvantaged by pandemic-related health care disruptions.

Incident Cancer Detection During Multiple Waves of COVID-19: The Tsunami After the Earthquake.

No population-based study exists to demonstrate the full-spectrum impact of COVID-19 on hindering incident cancer detection in a large cancer system. Building upon our previous publication in JNCCN, we conducted an updated analysis using 12 months of new data accrued in the pandemic era (extending the study period from September 26, 2020, to October 2, 2021) to demonstrate how multiple COVID-19 waves affected the weekly cancer incidence volume in Ontario, Canada, and if we have fully cleared the backlog at the end of each wave.

Cancer Patients First Treated with Chemotherapy: Are They More Likely to Receive Surgery in the Pandemic?

Due to the ramping down of cancer surgery in early pandemic, many newly diagnosed patients received other treatments first. We aimed to quantify the pandemic-related shift in rate of surgery following chemotherapy. This is a retrospective population-based cohort study involving adults diagnosed with cancer between 3 January 2016 and 7 November 2020 in Ontario, Canada who received chemotherapy as first treatment within 6-months of diagnosis. Competing-risks regression models with interaction effects were used to quantify the association between COVID-19 period (receiving a cancer diagnosis before or on/after 15 March 2020) and receipt of surgical reSection 9-months after first chemotherapy. Among 51,653 patients, 8.5% (n = 19,558) of them ultimately underwent surgery 9-months after chemotherapy initiation. Receipt of surgery was higher during the pandemic than before (sHR 1.07, 95% CI 1.02-1.13). Material deprivation was independently associated with lower receipt of surgery (least vs. most deprived quintile: sHR 1.11, 95% CI 1.04-1.17), but did not change with the pandemic. The surgical rate increase was most pronounced for breast cancer (sHR 1.13, 95% CI 1.06-1.20). These pandemic-related shifts in cancer treatment requires further evaluations to understand the long-term consequences. Persistent material deprivation-related inequity in cancer surgical access needs to be addressed.

The Changing Face of Cancer Surgery During Multiple Waves of COVID-19.

COVID-19 has had a detrimental effect on the provision of cancer surgery, but its impact beyond the first 6 months of the pandemic remains unclear. We used data on 799 220 cancer surgeries performed in Ontario, Canada, during 2018-2021 and segmented regression to address this knowledge gap. With the arrival of the first COVID-19 wave (March 2020), mean cancer surgical volume decreased by 57%. Surgical volume then rose by 2.5% weekly and reached prepandemic levels in 8 months. The surgical backlog after the first wave was 47 639 cases. At the beginning of the second COVID-19 wave (January 2021), mean cancer surgical volume dropped by 22%. Afterward, surgical volume did not actively recover (2-sided P = .25), resulting in a cumulative backlog of 66 376 cases as of August 2021. These data urge the strengthening of the surgical system to quickly clear the backlog in anticipation of a tsunami of newly diagnosed cancer patients in need of surgery.

Comparison of Use of Neoadjuvant Systemic Treatment for Breast Cancer and Short-term Outcomes Before vs During the COVID-19 Era in Ontario, Canada.

Importance: In response to an increase in COVID-19 infection rates in Ontario, several systemic treatment (ST) regimens delivered in the adjuvant setting for breast cancer were temporarily permitted for neoadjuvant-intent to defer nonurgent breast cancer surgical procedures. Objective: To examine the use and compare short-term outcomes of neoadjuvant-intent vs adjuvant ST in the COVID-19 era compared with the pre-COVID-19 era. Design, Setting, and Participants: This was a retrospective population-based cohort study in Ontario, Canada. Patients with cancer starting selected ST regimens in the COVID-19 era (March 11, 2020, to September 30, 2020) were compared to those in the pre-COVID-19 era (March 11, 2019, to March 10, 2020). Patients were diagnosed with breast cancer within 6 months of starting systemic therapy. Main Outcomes and Measures: Estimates were calculated for the use of neoadjuvant vs adjuvant ST, the likelihood of receiving a surgical procedure, the rate of emergency department visits, hospital admissions, COVID-19 infections, and all-cause mortality between treatment groups over time. Results: Among a total of 10 920 patients included, 7990 (73.2%) started treatment in the pre-COVID-19 era and 7344 (67.3%) received adjuvant ST; the mean (SD) age was 61.6 (13.1) years. Neoadjuvant-intent ST was more common in the COVID-19 era (1404 of 2930 patients [47.9%]) than the pre-COVID-19 era (2172 of 7990 patients [27.2%]), with an odds ratio of 2.46 (95% CI, 2.26-2.69; P < .001). This trend was consistent across a range of ST regimens, but differed according to patient age and geography. The likelihood of receiving surgery following neoadjuvant-intent chemotherapy was similar in the COVID-19 era compared with the pre-COVID-19 era (log-rank P = .06). However, patients with breast cancer receiving neoadjuvant-intent hormonal therapy were significantly more likely to receive surgery in the COVID-19 era (log-rank P < .001). After adjustment, there were no significant changes in the rate of emergency department visits over time between patients receiving neoadjuvant ST, adjuvant ST, or ST only during the ST treatment period or postoperative period. Hospital admissions decreased in the COVID-19 era for patients who received neoadjuvant ST compared with adjuvant ST or ST alone (P for interaction = .01 for both) in either setting. Conclusions and Relevance: In this cohort study, patients were more likely to start neoadjuvant ST in the COVID-19 era, which varied across the province and by indication. There was limited evidence to suggest any substantial impact on short-term outcomes.

Enhancing Outpatient Symptom Management in Patients With Head and Neck Cancer: A Qualitative Analysis.

IMPORTANCE: Patients with head and neck cancer manage a variety of symptoms at home on an outpatient basis. Clinician review alone often leaves patient symptoms undetected and untreated. Standardized symptom assessment using patient-reported outcomes (PROs) has been shown in randomized clinical trials to improve symptom detection and overall survival, although translation into real-world settings remains a challenge. OBJECTIVE: To better understand how patients with head and neck cancer cope with cancer-related symptoms and to examine their perspectives on standardized symptom assessment. DESIGN, PARTICIPANTS, AND SETTING: This was a qualitative analysis using semistructured interviews of patients with head and neck cancer and their caregivers from November 2, 2020, to April 16, 2021, at a regional tertiary center in Canada. Purposive sampling was used to recruit a varied group of participants (cancer subsite, treatment received, sociodemographic factors). Drawing on the Supportive Care Framework, a thematic approach was used to analyze the data. Data analysis was performed from November 2, 2020, to August 2, 2021. MAIN OUTCOMES AND MEASURES: Patient perception of ambulatory symptom management and standardized symptom assessment. RESULTS: Among 20 participants (median [range] age, 59.5 [33-74] years; 9 [45%] female; 13 [65%] White individuals), 4 themes were identified: (1) timely physical symptom management, (2) information as a tool for symptom management, (3) barriers to psychosocial support, and (4) external factors magnifying symptom burden. Participants' perceptions of standardized symptom assessment varied. Some individuals described the symptom monitoring process as facilitating self-reflection and symptom detection. Others felt disempowered by the process, particularly when symptom scores were inconsistently reviewed or acted on. CONCLUSIONS AND RELEVANCE: This qualitative analysis provides a novel description of head and neck cancer symptom management from the patient perspective. The 4 identified themes and accompanying recommendations serve as guides for enhanced symptom monitoring.

Impact of cancer surgery slowdowns on patient survival during the COVID-19 pandemic: a microsimulation modelling study.

BACKGROUND: With the declaration of the global pandemic, surgical slowdowns were instituted to conserve health care resources for anticipated surges in patients with COVID-19. The long-term implications on survival of these slowdowns for patients with cancer in Canada is unknown. METHODS: We constructed a microsimulation model based on real-world population data on cancer care from Ontario, Canada, from 2019 and 2020. Our model estimated wait times for cancer surgery over a 6-month period during the pandemic by simulating a slowdown in operating room capacity (60% operating room resources in month 1, 70% in month 2, 85% in months 3-6), as compared with simulated prepandemic conditions with 100% resources. We used incremental differences in simulated wait times to model survival using per-day hazard ratios for risk of death. Primary outcomes included life-years lost per patient and per cancer population. We conducted scenario analyses to evaluate alternative, hypothetical scenarios of different levels of surgical slowdowns on risk of death. RESULTS: The simulated model population comprised 22 799 patients waiting for cancer surgery before the pandemic and 20 177 patients during the pandemic. Mean wait time to surgery prepandemic was 25 days and during the pandemic was 32 days. Excess wait time led to 0.01-0.07 life-years lost per patient across cancer sites, translating to 843 (95% credible interval 646-950) life-years lost among patients with cancer in Ontario. INTERPRETATION: Pandemic-related slowdowns of cancer surgeries were projected to result in decreased long-term survival for many patients with cancer. Measures to preserve surgical resources and health care capacity for affected patients are critical to mitigate unintended consequences.

Virtual and in-person visits by Ontario physicians in the COVID-19 era.

INTRODUCTION: We examined the coronavirus disease 2019 (COVID-19) pandemic impact on weekly trends in the billing of virtual and in-person physician visits in Ontario, Canada. METHODS: In this retrospective cohort study, physician billing records from Ontario were aggregated on a weekly basis for in-person and virtual visits from 3 January 2016 to 27 March 2021. For each type of visit, a segmented negative binomial regression analysis was performed to estimate the weekly pre-pandemic trend in billing volume per thousand adults (3 January 2016 to 14 March 2020), the immediate change in mean volume at the start of the pandemic, and additional change in weekly volume in the pandemic era (15 March 2020 to 27 March 2021). RESULTS: Before the start of the pandemic, the weekly volume of virtual visits per thousand adults was low with a 0.5% increase per week (rate ratio [RR]: 1.0053, 95% confidence interval [CI]: 1.0050-1.0056). A dramatic 65% reduction in in-person visits (RR: 0.35, 95% CI: 0.32-0.39) occurred at the start of the pandemic while virtual visits grew by 21-fold (RR: 21.3, 95% CI: 19.6-23.0). In the pandemic era, in-person visits rose by 1.4% per week (RR: 1.014, 95% CI: 1.011-1.017) but no change was observed for virtual visits (p-value = 0.31). Overall, we noted a 57.6% increase in total weekly physician visits volume after the start of the pandemic. DISCUSSION: These results are meaningful for virtual care reimbursement models. Future study needs to assess the quality of care and whether the increase in virtual care volume is cost-effective to society.

Assessing the Impact of the COVID-19 Pandemic on Emergency Department Use for Patients Undergoing Cancer-Directed Surgeries.

Emergency department (ED) use is a concern for surgery patients, physicians and health administrators particularly during a pandemic. The objective of this study was to assess the impact of the pandemic on ED use following cancer-directed surgeries. This is a retrospective cohort study of patients undergoing cancer-directed surgeries comparing ED use from 7 January 2018 to 14 March 2020 (pre-pandemic) and 15 March 2020 to 27 June 2020 (pandemic) in Ontario, Canada. Logistic regression models were used to (1) determine the association between pandemic vs. pre-pandemic periods and the odds of an ED visit within 30 days after discharge from hospital for surgery and (2) to assess the odds of an ED visit being of high acuity (level 1 and 2 as per the Canadian Triage and Acuity Scale). Of our cohort of 499,008 cancer-directed surgeries, 468,879 occurred during the pre-pandemic period and 30,129 occurred during the pandemic period. Even though there was a substantial decrease in the general population ED rates, after covariate adjustment, there was no significant decrease in ED use among surgical patients (OR 1.002, 95% CI 0.957-1.048). However, the adjusted odds of an ED visit being of high acuity was 23% higher among surgeries occurring during the pandemic (OR 1.23, 95% CI 1.14-1.33). Although ED visits in the general population decreased substantially during the pandemic, the rate of ED visits did not decrease among those receiving cancer-directed surgery. Moreover, those presenting in the ED post-operatively during the pandemic had significantly higher levels of acuity.

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts. STUDY DESIGN: Retrospective review. SETTING: Multipractice study for community practices in Massachusetts. METHODS: Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19. RESULTS: The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP). CONCLUSION: COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Time to Surgery and Survival in Head and Neck Cancer.

BACKGROUND: The COVID-19 pandemic has required triage and delays in surgical care throughout the world. The impact of these surgical delays on survival for patients with head and neck squamous cell carcinoma (HNSCC) remains unknown. METHODS: A retrospective cohort study of 37 730 patients in the National Cancer Database with HNSCC who underwent primary surgical management from 2004 to 2016 was performed. Uni- and multivariate analyses were used to identify predictors of overall survival. Bootstrapping methods were used to identify optimal time-to-surgery (TTS) thresholds at which overall survival differences were greatest. Cox proportional hazard models with or without restricted cubic splines were used to determine the association between TTS and survival. RESULTS: The study identified TTS as an independent predictor of overall survival (OS). Bootstrapping the data to dichotomize the cohort identified the largest rise in hazard ratio (HR) at day 67, which was used as the optimal TTS cut-point in survival analysis. The patients who underwent surgical treatment longer than 67 days after diagnosis had a significantly increased risk of death (HR, 1.189; 95% confidence interval [CI], 1.122-1.261; P < 0.0001). For every 30-day delay in TTS, the hazard of death increased by 4.6%. Subsite analysis showed that the oropharynx subsite was most affected by surgical delays, followed by the oral cavity. CONCLUSIONS: Increasing TTS is an independent predictor of survival for patients with HNSCC and should be performed within 67 days after diagnosis to achieve optimal survival outcomes.

Development and validation of a Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN) in a scarce resource setting: Response to the COVID-19 pandemic.

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, access to surgical care for patients with head and neck cancer (HNC) is limited and unpredictable. Determining which patients should be prioritized is inherently subjective and difficult to assess. The authors have proposed an algorithm to fairly and consistently triage patients and mitigate the risk of adverse outcomes. METHODS: Two separate expert panels, a consensus panel (11 participants) and a validation panel (15 participants), were constructed among international HNC surgeons. Using a modified Delphi process and RAND Corporation/University of California at Los Angeles methodology with 4 consensus rounds and 2 meetings, groupings of high-priority, intermediate-priority, and low-priority indications for surgery were established and subdivided. A point-based scoring algorithm was developed, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). Agreement was measured during consensus and for algorithm scoring using the Krippendorff alpha. Rankings from the algorithm were compared with expert rankings of 12 case vignettes using the Spearman rank correlation coefficient. RESULTS: A total of 62 indications for surgical priority were rated. Weights for each indication ranged from -4 to +4 (scale range; -17 to 20). The response rate for the validation exercise was 100%. The SPARTAN-HN demonstrated excellent agreement and correlation with expert rankings (Krippendorff alpha, .91 [95% CI, 0.88-0.93]; and rho, 0.81 [95% CI, 0.45-0.95]). CONCLUSIONS: The SPARTAN-HN surgical prioritization algorithm consistently stratifies patients requiring HNC surgical care in the COVID-19 era. Formal evaluation and implementation are required. LAY SUMMARY: Many countries have enacted strict rules regarding the use of hospital resources during the coronavirus disease 2019 (COVID-19) pandemic. Facing delays in surgery, patients may experience worse functional outcomes, stage migration, and eventual inoperability. Treatment prioritization tools have shown benefit in helping to triage patients equitably with minimal provider cognitive burden. The current study sought to develop what to the authors' knowledge is the first cancer-specific surgical prioritization tool for use in the COVID-19 era, the Surgical Prioritization and Ranking Tool and Navigation Aid for Head and Neck Cancer (SPARTAN-HN). This algorithm consistently stratifies patients requiring head and neck cancer surgery in the COVID-19 era and provides evidence for the initial uptake of the SPARTAN-HN.