Sir — The COVID-19 outbreak in 2020 had a significant social, economic and health impact. Lockdown measurements and the overcharge on the healthcare system contributed to increasing the burden of cancer [1], especially in low- and middle-income countries that already had a collapsed healthcare system [2].
Even though the COVID-19 scenario is now more favourable, the outbreak's consequences must still be managed. As the stage at diagnosis is one of the most significant prognostic factors for cancer survivors, the stage shift [3] of patients to more advanced stages at diagnosis, due to restricted access to the healthcare system, is anticipated to result in an increase in mortality in the years to come. However, estimates of this consequence are still lacking.
Therefore, we used the official national public cancer registry data (DATASUS) to investigate the changes in staging patterns after the COVID-19 outbreak to identify the impact on staging patterns, thus enabling interventions to mitigate this effect.
DATASUS reported 561 039 new cancer cases in 2019, 502 766 in 2020 and 538 993 in 2021. Overall, there was a significant stage shift towards more advanced stages in 2020 and 2021 (P < 0.001; Pearson's chi-squared test), with an increase in stage III and IV cases and a decrease in stage I and II cases (Figure 1 ).
Fig. 1.
Relative distribution of new cancer cases per stage for patients diagnosed in 2019, 2020, and 2021.
This stage shift towards more advanced stages may result in a decrease in cancer survival for patients assisted by SUS (Brazilian public healthcare system), leading to deaths that could have been avoided if adequate cancer care access had been maintained during the pandemic. The Brazilian public health system has faced significant barriers to providing sufficient care for the population. During the COVID-19 outbreak, the system had to deal with an overwhelming increase in demand [4]. Other problems have emerged, including patients presenting with more advanced disease.
Acknowledging the situation is the first step for planning interventions that can ultimately address the existing barriers to decrease gaps in care. Our findings show that the impact of the COVID-19 outbreak will be seen in the forthcoming years and, more importantly, in the most vulnerable population. There is still an opportunity to develop strategies to mitigate those consequences. Models have shown that increasing cancer care can decrease the additional risk of dying [5]; therefore, interventions should be planned to target the areas that will experience a greater impact.
Ethical Approval
Because DATASUS is a national public database with no individual-level patient data, this study was exempted from additional ethical approval.
Data Availability
Research data are available upon request.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
CFPMdeS, MTMS, FCFR, ANR, HSdeCR, GdeC, GVA, SAH, FYdeM and GNM are guarantors of integrity of the entire study. CFPMdeS and GNM were responsible for study concepts and design, the literature research and manuscript preparation. CFPMdeS, MTMS, FCFR, ANR, HSdeCR, GdeC, GVA, SAH, FYdeM and GNM carried out the data analysis and edited the manuscript. CFPMdeS, GVA, FYdeM, GNM carried out the statistical analysis.
References
- 1.Blayney D.W., Bariani G., Das D., Dawood S., Gnant M., De Guzman R., et al. Spotlight on international quality: COVID-19 and its impact on quality improvement in cancer care. JCO Glob Oncol. 2021;7:1513–1521. doi: 10.1200/GO.21.00281. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Villain P., Carvalho A.L., Lucas E., Mosquera I., Zhang L., Muwonge R., et al. Cross-sectional survey of the impact of the COVID-19 pandemic on cancer screening programs in selected low- and middle-income countries: study from the IARC COVID-19 Impact Study Group. Int J Cancer. 2021;149(1):97–107. doi: 10.1002/ijc.33500. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Brierley J., O’Sullivan B., Asamura H., Byrd D., Huang S., Lee A., et al. Global consultation on cancer staging: promoting consistent understanding and use. Nat Rev Clin Oncol. 2019;16(12):763–771. doi: 10.1038/s41571-019-0253-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Rache B., Nunes L., Freitas R., Aguillar A., Bigoni A., Tasca R., et al. Pressões Orçamentárias da Saúde para 2021 e além. Inst Estud Para Políticas Saúde Nota Téc. 2021;22 22:5. [Google Scholar]
- 5.Matos L.L., Forster C.H.Q., Marta G.N., Castro Junior G., Ridge J.A., Hirata D., et al. The hidden curve behind COVID-19 outbreak: the impact of delay in treatment initiation in cancer patients and how to mitigate the additional risk of dying—the head and neck cancer model. Cancer Causes Control. 2021;32(5):459–471. doi: 10.1007/s10552-021-01411-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Research data are available upon request.