To the Editor:
We read with interest the letter from Mak et al1 concerning our study on the drop in colonoscopies during the lockdown in France.2 Indeed, we did not perform analyses concerning ethnicity or race, as such data are unavailable in France for legal and ethical reasons.
However, to gain insight into the role of social status, we performed a second analysis. Our national database (Programme de médicalisation des systèmes d'information), used in the article, provides the zip codes of patients’ residential communes. These codes are associated with the French deprivation (Fdep) index, which reports the level of precarity of each zip code.3 , 4 The calculation of this index is based on the unemployment rate, the worker rate, schooling rate, and monthly income. The higher the index the more disadvantaged is the zip code and, therefore, the commune.
During the lockdown period, the Fdep index increased significantly for patients who underwent colonoscopy compared to the prelockdown period (lockdown: 0.21 [95% confidence interval {CI}, –0.66; 0.90] vs before lockdown: 0.10 [95% CI, –0.81; 0.84]; P < .001). This reflects the fact that the ratio of colonoscopies in socioeconomically deprived communes was higher than in wealthier zones during the lockdown. For the most deprived communes, the ratio of performed colonoscopies increased (before lockdown: 25% vs lockdown 27%). Comparatively, the ratio of performed colonoscopies in the most wealthier communes decreased (before lockdown: 25% vs lockdown 22%). Deprived communes were not the most impacted by the decrease of activity. Moreover, the Fdep was not significantly different before and after the lockdown (before lockdown: 0.10 [95% CI, –0.81; 0.84] vs after lockdown: 0.10 [95% CI, –0.80 to 0.83]; P = .66).
The first explanation of this finding is that the major decrease of activity was observed in the largest communes, with a low Fdep, where university hospitals and large private clinics stand. Interestingly, there was no catch-up during the postlockdown period for nondeprived communes, as the index did not decrease significantly. A second explanation is the characteristics of the French health care system, which provides almost universal medical coverage for the entire population, reducing the impact of socioeconomic criteria on the screening or treatment of medical diseases.
We agree with the comment regarding a possible increased mortality of colorectal cancer due to more advanced stages. In a previous study, we did not report association between digestive elective surgery during the lockdown and postoperative death.5 Only a coronavirus disease 2019 infection was a risk factor for postoperative mortality. Further analyses are needed to evaluate the impact of the different lockdowns and the global coronavirus disease 2019 pandemic on colorectal cancer treatment with a long-term follow-up. The rate of patients requiring adjuvant chemotherapy after resection may be a good surrogate marker to be evaluated.
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Conflict of interest/Disclosure
No conflicts of interest to report.
References
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