Abstract
This retrospective cohort study assesses delays in diagnosis and treatment for patients with oral squamous cell carcinoma in a tertiary care university hospital in Naples, Italy.
Delays in the diagnosis and treatment of patients with cancer are associated with poor outcomes. Although essential health care services such as surgical and medical oncology were generally not suspended during the COVID-19 pandemic worldwide, mandatory quarantine and other lockdown measures may have led to unintended detrimental effects on early cancer detection and treatment. Recent work1,2 has pointed to the fragility of cancer surgery systems globally, with an estimated 1 in 7 patients who were in regions with full lockdowns not undergoing planned surgery or experiencing longer preoperative delays.
Methods
We retrospectively assessed the delays in patients diagnosed with oral squamous cell carcinoma (OSCC) in a tertiary care University Hospital in Naples, Italy, during a 2-year period. The study was approved by the institutional review board of the University of Campania, and written informed consent was given by participants. Seventy (34 women) newly diagnosed patients with histopathologically confirmed OSCC were stratified into 2 groups: patients attending the Maxillofacial Surgery Unit of the University of Campania “Luigi Vanvitelli” before and during COVID-19 pandemic, respectively. The time elapsed between self-reported onset of symptoms and the first specialist consult was considered as patient delay (D1) and the time between the first consultation and diagnosis was considered as professional delay (D2). The total diagnostic delay (DD) was calculated as D1 + D2. The duration between the final diagnosis and the beginning of the proposed treatment was referred to as treatment delay (D3). Effect size was assessed as small (d = 0.2), medium (d = 0.5), and large (d = 0.8) based on benchmarks suggested by Cohen.3
Results
The mean (SD) DD detected in the whole cohort spanning 2019 and 2020 was 136.47 (71.34) days (median, 131; range, 21-367 days). Subgroup analysis per year showed that longer diagnostic delay was observed in 2020 compared with 2019 (Table). Compared with the prepandemic year, patients diagnosed with OSCC in 2020 experienced an additional delay of 35.57 days (95% CI, 5.6-65.54) for D1, 21.43 days (95% CI, 4.43-38.43) for D2, and 57 days (95% CI, 25.62–88.38) for DD. Cohen d showed a medium effect size for D1 (d = 0.57) and D2 (d = 0.60), and a large effect for overall DD (d = 0.91). There was a slight decrease in the mean (SD) D3 in 2020 compared with 2019 (20.00 [14.50] vs 26.82 [31.76] days), and this difference was classified as a small difference (d = 0.27). Overall, treatment options included surgery (41 [58.6%]), radiotherapy (6 [8.6%]), chemotherapy (1 [1.4%]), combined chemotherapy and radiation treatment (12 [17.1%]), whereas 10 patients (14.3%) were lost to follow-up after diagnosis or refused the proposed treatment plan.
Table. Patient Characteristics.
| Characteristic | Total cohort (n = 70) | 2019 Cohort (n = 35) | 2020 Cohort (n = 35) |
|---|---|---|---|
| Sex, No. | |||
| Female | 34 | 16 | 18 |
| Male | 36 | 19 | 17 |
| Age, mean (SD), y | 67 (12) | 68 (10) | 65 (14) |
| Cancer stage, No. (%) | |||
| I | 12 (17.1) | 6 (17.1) | 6 (17.1) |
| II | 14 (20) | 7 (20) | 7 (20) |
| III | 11 (15.7) | 6 (17.1) | 5 (14.3) |
| IVA | 16 (22.9) | 12 (34.3) | 5 (14.3) |
| IVB | 16 (22.9) | 4 (11.4) | 12 (34.3) |
| Therapy, No. (%) | |||
| Surgery | 41 (58.6) | 25 (71.4) | 16 (45.7) |
| Radiotherapy | 6 (8.6) | 1 (2.9) | 5 (14.3) |
| Chemotherapy | 1 (1.4) | 0 | 1 (2.9) |
| Radio/chemotherapy | 12 (17.1) | 7 (20) | 5 (14.3) |
| Refused/lost at follow-up | (14.3) | 2 (5.7) | 8 (22.9) |
| Delay, mean (SD), d | |||
| D1 | 100.56 (64.89) | 82.77 (46.94) | 118.34 (75.44) |
| D2 | 35.91 (36.98) | 25.20 (22) | 46.63 (45.34) |
| D3 | 23.75 (25.52) | 26.82 (31.76) | 20.00 (14.50) |
| DD | 136.47 (71.34) | 107.97 (53.14) | 164.97 (76.36) |
Abbreviations: D1, patient delay; D2, professional delay; D3, treatment delay; DD, total diagnostic delay.
In a sensitivity analysis, tight lockdown measures (March 2020-May 2020) were not associated with a significant increase in delay for any variable compared with the whole 2020 (Mann-Whitney test). When compared with 2019 and after controlling for age, sex, and stage of tumor, patients in 2020 experienced a mean (SD) 55.11 (15.92) (95% CI, 23.30-86.92) additional days of diagnostic delay.
Discussion
In Italy, lockdown restrictions and COVID-19 collateral effects on health care were severe.4,5 Movement restrictions and limited access to primary care may have negatively affected patient-related delay in our cohort. Importantly, practitioner delays are widely dependent on regional health care policies and internal organizational structure and, as such, should be amenable to targeted interventions in response to emerging circumstances. Our findings show that while professional diagnostic delay (D2) was significantly increased in 2020, treatment delay was not. In general, patients attend outpatient service for diagnostic procedures, and once surgery is scheduled, they are admitted for inpatient care. This suggests that inpatient service for OSCC was not disrupted during COVID-19 in this single university hospital. A limitation of this study stems from the limited external validity of the data. Furthermore, multiple social and health care–related changes occurring during the COVID-19 pandemic and not specifically considered in this study may have contributed to the increased delay observed in our research.
Because evidence of the collateral effects of pandemic lockdowns has salient implications in terms of local health policies, awareness of patterns and delays in the diagnosis and treatment of patients with OSCC may inform future decisions involving a restricted access to health care in South Italy and worldwide.
References
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