COVID-19 and liver cancer: lost patients and larger tumours

Abstract

BackgroundNorthern England has been experiencing a persistent rise in the number of primary liver cancers, largely driven by an increasing incidence of hepatocellular carcinoma (HCC) secondary to alcohol-related liver disease and non-alcoholic fatty liver disease. Here we review the effect of the COVID-19 pandemic on primary liver cancer services and patients in our region.ObjectiveTo assess the impact of the COVID-19 pandemic on patients with newly diagnosed liver cancer in our region.DesignWe prospectively audited our service for the first year of the pandemic (March 2020–February 2021), comparing mode of presentation, disease stage, treatments and outcomes to a retrospective observational consecutive cohort immediately prepandemic (March 2019–February 2020).ResultsWe observed a marked decrease in HCC referrals compared with previous years, falling from 190 confirmed new cases to 120 (37%). Symptomatic became the the most common mode of presentation, with fewer tumours detected by surveillance or incidentally (% surveillance/incidental/symptomatic; 34/42/24 prepandemic vs 27/33/40 in the pandemic, p=0.013). HCC tumour size was larger in the pandemic year (60±4.6 mm vs 48±2.6 mm, p=0.017), with a higher incidence of spontaneous tumour haemorrhage. The number of new cases of intrahepatic cholangiocarcinoma (ICC) fell only slightly, with symptomatic presentation typical. Patients received treatment appropriate for their cancer stage, with waiting times shorter for patients with HCC and unchanged for patients with ICC. Survival was associated with stage both before and during the pandemic. 9% acquired COVID-19 infection.ConclusionThe pandemic-associated reduction in referred patients in our region was attributed to the disruption of routine healthcare. For those referred, treatments and survival were appropriate for their stage at presentation. Non-referred or missing patients are expected to present with more advanced disease, with poorer outcomes. While protective measures are necessary during the pandemic, we recommend routine healthcare services continue, with patients encouraged to engage.

Healthcare in England was affected by the COVID-19 pandemic across the pancreatic cancer pathway: a cohort study using OpenSAFELY-TPP

“…We found that many of the pancreatic cancer-related services were disrupted across the pathway of care. This is in line with previous reports about healthcare being negatively affected by the COVID-19 pandemic [3][4][5][6][7][8][9][11][12][13][14]. Healthcare assessments, such as BMI, HbA1c and liver function, were delivered to fewer people than would be expected if the pandemic had not occurred.…”

“…Cancer services were already overstretched before the COVID-19 pandemic [1,2]. With the widespread effect on healthcare, the pandemic further exacerbated the cancer-related healthcare crisis [3][4][5][6][7][8][9][10][11][12][13][14]. During the pandemic, the resources, and the attention in healthcare systems globally, shifted towards preventing and managing COVID-19 [15,16].…”

COVID-19 and liver disease

“…This has resulted in delayed presentation and hospitalisation of sicker patients with advanced cirrhosis, increased liver-related mortality and a reduction in overall patient satisfaction 59 61. The strain on healthcare resources and prioritisation of social distancing has also led to interrupted HCC surveillance programmes leading to delayed presentation and increased tumour size at diagnosis compared with the pre-pandemic era 62 63…”

SARS-CoV-2-mediated liver injury: pathophysiology and mechanisms of disease

“…Consistently, HCC tumor sizes were bigger during the pandemic year (60 4.6 mm vs 48 2.6 mm, p = 0.017), and spontaneous tumor hemorrhage was more common. Slightly fewer new cases of intrahepatic cholangiocarcinoma (ICC) were reported, although symptoms were frequently present [ 87 ]. Patients with high risk of liver malignancies, particularly those with advanced tumor stages, may have high mortality rate.…”