Study: Pandemic contributed to gastrointestinal cancer underdiagnosis

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The COVID-19 pandemic likely contributed to the underdiagnosis of patients with high-risk gastrointestinal (HRGI) cancers and increased diagnoses of stage 4 cancers, but there was no change in 1-year survival or operative mortality among patients with HGRI cancers in 2020, according to research published yesterday in JAMA Network Open.

The findings add to the growing body of literature describing if and by how much the shutdowns of the early pandemic contributed to an increase in delayed cancer diagnosis. Prior research has shown that missed diagnoses of breast and prostate cancers, which are regularly detected during annual screenings, increased in 2020. Other research has shown that, before the widespread availability of vaccines, cancer patients suffered worse outcomes.

Almost half had pancreatic cancer

In the new study, investigators looked at patients with HRGI cancers, including esophageal, gastric, primary liver, and pancreatic cancers. Those cancer patients already more often seek care at advanced stages and have increased risks of perioperative mortality and worse survival.

The study included patients identified via the National Cancer Database from January 1, 2018, through December 31, 2020.

In total 156,937 patients with these cancers were identified and followed up for at least 1 year. The primary outcomes were trends in newly diagnosed cases, stage at diagnosis, and mortality, the authors said.

In total, 33.2% of patients were diagnosed in 2018, 34.5% in 2019, and 32.3% in 2020. Of the included patients, 17.4% had esophageal cancer, 13.5% had gastric cancer, 23.1% had primary liver cancer, and 45.9% had pancreatic cancer. Almost 64% were men, and 35% were between the ages of 60 and 69.

3,000 fewer cases in first months of pandemic

Newly diagnosed HRGI cancers in March through May 2020, compared with diagnoses made during the same timeframe in prior years, were significantly lower, with at least 3,000 fewer cases diagnosed in 2020. In April 2020 alone, there were 1,500 fewer new cases of HRGI cancers than in the prior year.

Patients with HRGI were also more likely diagnosed in later stages of their disease in 2020. Stage 1 diagnoses dropped by 3.9% in 2020, and stage 2 diagnoses by 2.3%, but stage 4 diagnoses increased by 7.1%.

"During the early months of the pandemic, patients with milder symptoms may have delayed seeking medical advice, whereas those with severe symptoms due to advanced disease had to seek care by necessity," the authors said.

During the early months of the pandemic, patients with milder symptoms may have delayed seeking medical advice.

One-year mortality rates, however, did not increase during 2020. Though 1-year survival rates in 2020 were 47.4% compared with 50.7% in both 2018 and 2019, a multivariable Cox regression showed that patients diagnosed in 2020 were not more likely to experience mortality at 1 year (hazard ratio, 0.99; 95% confidence interval, 0.97 to 1.01).

"The findings of this national study of patients with newly diagnosed HRGI cancers suggest substantial underdiagnosis in the first year of the pandemic," the authors wrote. "Additionally, patients more frequently presented with advanced-stage disease; however, at a time when the pandemic was disrupting health care, it is a tribute to the efforts of cancer clinicians that 1-year survival curves and operative mortality remained unchanged, as our findings suggest."

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