The Challenges of Colorectal Cancer Surgery during the COVID-19 Pandemic in Romania: A Three-Year Retrospective Study

Abstract

The predictions on the influence of the SARS-CoV-2 pandemic on access to medical services in Romania predicted a 35% drop in oncological hospitalizations in 2020 compared to the previous decade, raising the hypothesis that patients with colorectal cancer can become indirect victims of the ongoing pandemic. Therefore, the aim of the current research was to observe how the COVID-19 pandemic influenced colorectal cancer surgery in Romania, to determine the level of addressability towards specialized care, to compare the cancer staging between the pandemic and pre-pandemic periods, and to observe the risk factors for disease progression. This retrospective study was spread over three years, respectively, from March 2019 to March 2022, and included a total of 198 patients with a history of colorectal cancer surgery. It was decided to perform a parallel comparison of 2019, 2020, and 2021 to observe any significant changes during the pandemic. Our clinic encountered a significant decrease in all interventions during the pandemic; although the number of CRC surgeries remained constant, the cases were more difficult, with significantly more patients presenting in emergency situations, from 31.3% in 2019 to 50.0% in 2020 and 57.1% in 2021. Thus, the number of elective surgeries decreased significantly. The proportion of TNM (tumor-node-metastasis) staging was, however, statistically significant between the pre-pandemic and pandemic period. In 2019, 13.3% of patients had stage IIa, compared with 28.8% in 2020 and 13.1% in 2021. Similarly, the proportion of very advanced colorectal cancer was higher during the pandemic period of 2020 and 2021 (12.0% in 2019 vs. 12.5% in 2020 and 25.0% in 2021), which was represented by a significantly higher proportion of patients with bowel perforation. Patients with an advanced TNM stage had a 6.28-fold increased risk of disease progression, followed by lymphovascular invasion (HR = 5.19). However, the COVID-19 pandemic, represented by admission years 2020 and 2021, did not pose a significant risk for disease progression and mortality. In-hospital mortality during the pandemic also did not change significantly. After the pandemic restrictions have been lifted, it would be advisable to conduct a widespread colorectal cancer screening campaign in order to identify any instances of the disease that went undetected during the SARS-CoV-2 pandemic.

Global elective breast- and colorectal cancer surgery performance backlogs, attributable mortality and implemented health system responses during the COVID-19 pandemic: A scoping review

“…The final review comprised 39 primary research articles (20 case series, 7 cross-sectional studies, 4 cohort studies, 1 case-control study, 4 ecologic studies, 2 research letters and 1 qualitative study,) and 11 reviews (including 2 systematic reviews) ( Fig 1 ) [ 5 – 7 , 9 , 18 , 21 – 27 , 38 – 75 ]. At the time of review, two of the included studies were preprints [ 57 , 74 ].…”

“…Most of the included articles were from high-income countries (HICs) (i.e., n = 38, 76.0% from HICs and n = 12, 24.0% from low- and middle-income countries [LMICs]). Seventeen studies reported on the ‘impact of COVID-19’ [ 25 , 27 , 44 , 47 , 48 , 50 – 52 , 57 , 68 – 73 , 75 ], 30 reported on ‘health system responses, effects or challenges’ [ 6 , 7 , 18 , 21 – 24 , 38 , 40 – 43 , 45 , 46 , 49 , 53 – 56 , 58 – 67 , 74 ] and 3 reported on both [ 5 , 26 , 39 ]. We present the key findings below in a narrative synthesis, according to the primary outcomes ( S1 Checklist ).…”

“…Five case-series studies, conducted at an institutional level, compared the number of colorectal cancer procedures performed during the pandemic to that performed during preceding years, pre-COVID-19; one of the studies was from an UMIC (China) and four were from HICs (Italy, Romania, Croatia) [ 39 , 57 , 68 , 70 , 75 ]. The relative percentage reduction in the institutional volume of elective colorectal procedures performed ranged from 11.08%–57.3% across these studies [ 39 , 57 , 68 , 70 , 75 ].…”

“…Eleven of the 18 studies that reported on elective surgery activity were undertaken at an institutional level, which limited their statistical power to show a difference [5,26,39,57,[68][69][70][71][72][73]75]. Case performance reductions were not caused solely by elective surgery service suspensions; ancillary pandemic-or patient-specific determinants are tabulated (Table 5).…”