How Many Lives Will Delay of Colon Cancer Surgery Cost During the COVID-19 Pandemic? An Analysis Based on the US National Cancer Database

To the Editor:

By May 13, 2020, 1,342,594 cases of coronavirus disease (COVID-19) had been confirmed in the United States.¹ Of these patients, 80,820 (6%) had died.¹ This rapid viral spread, unencumbered by an effective treatment or vaccine, required wise health care resource utilization decisions. Consequently, many centers throughout the world have decided to delay elective surgical procedures including those for cancer to avoid health care 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, which concluded that delaying elective surgery for patients with stage I to III colon cancer was independently associated with the decrease in the 5-year overall survival.⁵ Therefore, we have attempted to place into context the potential impact of delay of surgical treatment for patients with colon cancer in the setting of the COVID-19 pandemic.

Within our previous series,⁵ 30,937 deaths (26%) occurred among 118,504 patients with colon cancer during a 5-year follow-up. Delaying the surgical resection for patients with stage I to III colon cancer was associated with an increase in the mortality rate within the 5 years of follow-up (25% mortality rate when surgery was performed within 1 month of diagnosis vs 37% after a 4-month delay). This increase in death from cancer was already apparent within the first year (Figure ), highlighting the urgency and impact of our nation’s health care decisions.

Figure.

Risk of death within 5 years (A) and 1 year (B) after surgery according to the duration of the delay from diagnosis to surgery. Exp = expected.

^aDeath within 1 year after surgery. ^bDeath more than 1 year after surgery (the percentage presented is the number of deaths within 1 year divided by the number of deaths within 5 years). ^cThe expected number of deaths according to the duration of delay between the diagnosis and surgery. The estimated total number of cases of stage I to III colon cancer in 2020 is 83,688 patients.³ Of these patients, based on our previous study’s results, 21,759 deaths (26%) would be expected within a 5-year follow-up. To calculate the predicted number of deaths for each delay in surgery period 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.

In the United States, we expect to have 104,610 new cases of colon cancer in 2020 with about 83,688 patients having stage I to III colon cancer.³ This incidence will result in 20,922 (25%) expected deaths within 5 years of surgery if performed within 30 days of diagnosis (Figure). 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 5-year period. This potential tragic outcome may result in an additional loss of 10,043 Americans over 5 years (Figure). This model may be an underestimate, as some patients may die before ever undergoing surgical treatment and are not counted. Moreover, this estimate 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 the Figure.

Therefore, political and health care 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 referral of patients for 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.