Background: This study aimed to identify areas for health system strengthening by comparing the delivery of elective cancer surgery during periods of COVID-19 lockdowns versus light restrictions.
Methods: This international, prospective cohort study enrolled patients with 15 cancer types who had a decision for surgery during the COVID-19 pandemic up to 31st August 2020 (NCT04384926). Average national Oxford COVID-19 Stringency Index scores were calculated for each patient during the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20-60), and full lockdowns (>60). The primary outcome was the non-operation rate (proportion of patients who did not undergo their planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation.
Findings: Of 20,006 patients (466 hospitals, 61 countries), 9.1% did not receive surgery after a minimum of 3-months’ follow up (median: 23-weeks, IQR:16-30), all of whom had a COVID-19 related reason for non-operation. Light restrictions were associated with a 0.6% non-operation rate, moderate lockdowns a 5.5% rate (adjusted hazard ratio: 0.81, 95% confidence interval 0.77-0.84, p<0.001), and full lockdowns a 15.0% rate (HR:0.51, 0.50-0.53). Upon sensitivity analysis including adjustment for SARS-COV-2 Case rates, moderate and full lockdowns remained independently associated with non-operation. Frail patients, those with advanced cancer, and patients in lower-middle income countries less likely to undergo surgery.
Discussion: Cancer systems worldwide were fragile to lockdowns, with one in seven patients not undergoing planned surgery. The resilience of surgical systems requires strengthening through protected elective pathways and investment in surge capacity for public health emergencies.
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