Regarding ‘Impact of the COVID-19 Outbreak on Cancer Staging in Brazil’: Navigating the Impact of the Pandemic on Neuro-Oncology Procedures

Sir — We read with interest the letter recently published in Clinical Oncology by de Sousa and collaborators [1] and congratulate the authors on their work. Although it provided valuable insights into the pandemic's impact on cancer staging in Brazil, we want to highlight the specific impact on neuro-oncology surgical care.

Neuro-oncology centres globally witnessed a decline in patient referrals, new diagnoses and treatment numbers. Strategies such as national protocols and telemedicine to manage non-critical patients were used [2]. However, Brazil's public health system primarily supports people with low education and income, making accessibility a significant issue. It was not possible to standardise these measures for the entire population and there was the lack of a national protocol to address this issue.

We investigated the impact of the COVID-19 pandemic on neurosurgical procedures in the Brazilian public health system by collecting monthly neuro-oncological procedure data from January 2017 to September 2021, sorted by elective or urgent. We compared productivity between the pre-pandemic period (until March 2020) and the pandemic period using descriptive and simple inferential analyses.

Neurosurgical procedures in the Brazilian public health system decreased by 22.2% during the pandemic period, particularly elective surgeries, which dropped by 42.82%. The mean number of monthly elective brain tumour surgeries decreased by 22.9% (P < 0.001; Figure 1 ). The elective procedures that were significantly impacted (P < 0.001) were skull base tumours (–64.1%), transsphenoidal hypophysectomy (–55%) and other types of intracranial tumour (–17.1%), as seen in Table 1 . Urgent procedures, conversely, increased by 6.3% (P < 0.001).

Fig 1.

Neuro-oncology procedure trends in Brazil between 2017 and September 2021.

Table 1.

Mean of neuro-oncology procedures in the pre-pandemic and pandemic periods sorted by character of care

Procedure	Urgency			Elective
Tumour	Pre-pandemic	Pandemic	Ratio	Pre-pandemic	Pandemic	Ratio
Cranial biopsy	26 ± 6.1	23.4 ± 6.9	–10.0∗∗∗	7.4 ± 2.8	5.9 ± 3	–20.3∗∗∗
Intracranial tumour	208.5 ± 22.7	223.8 ± 50.3	+7.3∗†	115.2 ± 15.8	95.5 ± 24.1	–17.1∗∗†
Craniotomy for brain tumour	66.3 ± 11.3	60.9 ± 14	–8.1∗∗∗†	31.5 ± 6	21.1 ± 6.6	–33.1∗∗
Skull base tumour	13.7 ± 4.5	13.8 ± 4.3	+0.6∗∗∗†	10.4 ± 3.8	3.7 ± 2.6	–64.1∗∗
Orbit tumour	2.4 ± 1.7	1.8 ± 1.5	–24.4∗∗∗	4.1 ± 2.4	3.1 ± 1.7	–26.6∗∗∗
Transsphenoidal hypophysectomy	14.3 ± 4.5	12.5 ± 5.6	–12.7∗∗∗	35.4 ± 6.7	15.9 ± 7.6	–55.0∗∗†

∗P < 0.05.

∗∗P < 0.00.

∗∗∗P > 0.05.

^†Mann–Whitney U test.

Neuro-oncology patients in Brazil may have missed the optimal timing to undergo surgery during the pandemic period, which could have led to worse outcomes. Delayed or deferred surgeries may have caused patients to lose functionality and become dependent on others, resulting in increased costs for rehabilitation and support. Moreover, inadequate cancer care during the pandemic may have led to avoidable deaths.

Ethics

Because DATASUS is a national public database with no individual-level patient data, this study was exempt from additional ethical approval.

Data availability

Research data are available upon request.

Author contributions

LPFM, VECS, IMA and NNR are guarantors of integrity of the entire study. LPFM, VECS and IMA were responsible for study concepts and design, the literature research and manuscript preparation. LPFM carried out the data analysis and edited the manuscript. LPFM carried out the statistical analysis.

Conflicts of Interest

The authors declare no conflicts of interest.