The coronavirus disease 2019 (COVID-19) pandemic and subsequent public shutdowns led to significant disruptions to medical care in 2020, with 94% of neuro-oncology practitioners reporting changes to clinical practice.1,2 Prior studies have shown that there was significant care disruption (including delays and cancelations) for cases diagnosed with cancer.3 Unlike many other cancer types, our prior work suggests that there was little disruption in the new diagnosis of glioblastoma (unpublished data). Disruptions in various aspects of brain tumor management due to the COVID-19 pandemic have also been previously documented by survey studies,4 but analysis of retrospective data has been limited. Here, we utilized a database containing >85% of new primary brain tumor diagnoses5 to assess the effect of the pandemic on treatment patterns for glioblastoma in the United States.
IDHwt glioblastoma (ICD-O-3 code 9440 and Brain Molecular Marker site-specific data item #3816 value of 5) cases were retrieved from the National Cancer Database, a project of the Commission on Cancer, for cases 40+ years of age diagnosed from 2018 to 2020. Logistic regression was used to generate odds ratios, 95% confidence intervals, and P values of receiving resection, chemotherapy, or radiation after diagnosis for cases diagnosed in 2020 and 2018 as compared to 2019, after adjustment for potential confounders found to be significantly associated with treatment receipt, including age, sex, race/ethnicity, insurance type, average zip code household income, residential distance from facility, comorbidity score, facility type, region, and MGMT promoter methylation. Among individuals who received treatment and treatment time was known, logistic regression was used to estimate the odds of delayed time to treatment (>7 days for first surgery, >45 days for radiation, and >45 days for chemotherapy), adjusted for confounders. This cutoff was set at the 75th percentile of each time variable in the 2018–2019 period, representing a clinically significant delay in treatment. As a sensitivity analysis, we repeated analyses using only 2020 cases with a recorded COVID-19 test at an academic center (presumed to have earlier testing capability and indicative of diagnosis during the pandemic) compared to 2019.
There were 7174 newly diagnosed glioblastoma cases reported to NCDB in 2020, compared to 6266 in 2018 and 7135 cases in 2019. There was no significant difference in the odds of receiving treatment in 2020 (Figure 1A). For those who received treatment, a greater but nonsignificant proportion diagnosed in 2020 began treatment in ≤45 days (Figure 1B). In a fully adjusted model, the odds of delayed treatment initiation were nonsignificantly lower. There were no significant differences in the proportion of glioblastoma that received treatment nor were differences in time to treatment observed, including after stratifying by MGMT methylation. There were no significant differences when analyses were repeated in those diagnosed in 2020 who received COVID testing at an academic center.
Figure 1.
(A) The adjusted odds and 95% confidence intervals of receiving treatment1 in 2018 and 2020 compared to 2019 for IDHwt glioblastoma (IDHwt GB), and (B) the proportion of cases with IDHwt GB that received treatment within 45 days of diagnosis (7 days for surgery).
Though the disruptions to medical care caused by COVID-19 pandemic restrictions had significant effects on cancer incidence and treatment, these data suggest that the impact on glioblastoma treatment was minimal, as compared to other cancer types such as head and neck cancer where significant delays have been observed.6 Receiving a glioblastoma diagnosis in 2020 did not decrease the odds of treatment compared to 2019, nor did it decrease time to treatment. There are several limitations to this evaluation. The dataset utilized does not include the month of diagnosis, and it is not possible to know if the diagnosis occurred after shutdowns began in March 2020. Restrictions to those who received COVID-19 testing may not fully capture early pandemic diagnoses when restrictions were most severe, as testing was slow to be fully implemented in the United States. Universal testing became commonplace only after restrictions began loosening in many locations. Among individuals tested for COVID-19 at academic facilities, the odds of treatment and time to treatment were no different from previous years. Further research is required to determine the impact these treatment disruptions had on outcomes for cases with glioblastoma, especially in nonacademic facilities.
Contributor Information
Corey Neff, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
Mackenzie Price, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
Gino Cioffi, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Trans-Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA.
Kristin A Waite, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Trans-Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA.
Carol Kruchko, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA.
J Bryan Iorgulescu, Molecular Diagnostics Laboratory, Department of Hematopathology, Division of Pathology and Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Jill S Barnholtz-Sloan, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Trans-Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA; Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, Maryland, USA.
Quinn T Ostrom, Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA; Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA; The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA.
Conflict of interest statement
J.S.B.-S. is a full-time employee of the NIH/NCI. G.C. and K.W. are full-time contractors of the National Institutes of Health/ National Cancer Institute.
Funding
Funding for CBTRUS was provided by the Centers for Disease Control and Prevention (CDC) under Contract No.75D30119C06056/Amendment 0003, the American Brain Tumor Association, Novocure, the Musella Foundation for Brain Tumor Research & Information, Inc., National Brain Tumor Society, the Pediatric Brain Tumor Foundation, The Sontag Foundation, the Uncle Kory Foundation, National Cancer Institute (NCI), Neuro-Oncology Branch under Contract No.75N91022P00766, the Zelda Dorin Tetenbaum Memorial Fund, as well as private and in-kind donations. The research services of J.S.B.-S., K.A.W., and G.C. were provided by the Division of Cancer Epidemiology and Genetics of the NCI.
Author contributions
J.B.I, Q.T.O.: Conceptualization; C.N., G.C., J.B.I., Q.T.O.: Methodology; C.N., Q.T.O., C.N.: Analysis, visualization; Original draft preparation; Q.T.O.: Supervision; C.N., M.P., G.C., K.A.W., C.K., J.B.I., J.S.B.-S, Q.T.O.: Reviewing and editing.
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