How much have covid-19 pandemic waves impacted the number of lung cancer surgeries

The emergence of the covid-19 pandemic had a disruptive effect on health services worldwide. As more resources were needed to face the epidemiologic threat, even non-elective services suffered a reduction in funding and capacity. Lung cancer care has been affected by this health crisis. Studies have shown a reduction in the diagnosis of this disease after the pandemic's onset and a significant decrease in lung cancer screening [1Greene G. Griffiths R. Han J. Akbari A. Jones M. Lyons J. Lyons R.A. Rolles M. Torabi F. Warlow J. Morris E.R.A. Lawler M. Huws D.W. in Wales, UK, using a national cancer clinical record system.Br. J. Cancer. 2022; 127: 558-568https://doi.org/10.1038/s41416-022-01830-6Crossref PubMed Scopus (6) Google Scholar, 2Van Haren R.M. Delman A.M. Turner K.M. Waits B. Hemingway M. Shah S.A. Starners S.L. Impact of the COVID-19 pandemic on lung cancer screening program and subsequent lung cancer.J. Am. Coll. Surg. 2021; 232: 600-605https://doi.org/10.1016/j.jamcollsurg.2020.12.002Crossref PubMed Scopus (54) Google Scholar]. The low-dose computed tomography (LDCT) performance rate among Medicare beneficiaries in the United States of America was 24% (95% CI, 23%–24%) lower than expected between March 2020 and February 2021. Even considering the period between March 2021 and February 2022 – i.e., a most distant phase of the initial disruption of health services due to the pandemic –, the LDCT performance rates remained lower than expected [[3]C. Doan, S. Li, J.S. Goodwin. Breast and lung cancer screening among Medicare enrollees during the COVID-19 pandemic. JAMA Netw. Open. 6 (2023) e2255589. doi: 10.1001/jamanetworkopen.2022.55589.Google Scholar]. A population-based study in Ontario, Canada, indicated that the weekly incidence of lung cancer reduced immediately after the onset of the pandemic (in March 2020) and this rate continued to decline until at least September 2020 – the final period of the study. Between March and September 2020, the study estimated that approximately 870 lung cancer cases were undiagnosed in this province [[4]Eskander A. Li Q. Yu J. Hallet J. Coburn N.G. Dare A. Chan K.K.W. Singh S. Parmar A. Earle C.C. Lapointe-Shaw L. Krzyzanowska M.K. Hanna T.P. Finelli A. Louie A.V. Hong N.L. Irish J.C. Witterick I.J. Mahar A. Noel C.W. Urbach D.R. McIsaac D.I. Enepekides D. Sutradhar R. Incident cancer detection during the COVID-19 pandemic.J. Natl. Compr. Cancer Netw. 2022; 20: 276-284https://doi.org/10.6004/jnccn.2021.7114Crossref PubMed Google Scholar]. In Brazil, Federal Law N. 12,732/2012 stipulates that cancer patients have the right to begin treatment within up to two months of diagnosis [[5]França M.A.S.A. Nery N.G. Antunes J.L.F. Freire M.D.C.M. Timeframe for initiating oral cancer treatment in Brazil since approval of new legislation in 2012: time trend, 2013–2019.Cad Saude Publica. 2021; 37: e00293220https://doi.org/10.1590/0102-311X00293220Crossref PubMed Scopus (2) Google Scholar]. We used data from the Ministry of Health (System of Hospital Information: https://datasus.saude.gov.br/transferencia-de-arquivos/) from 2018 to 2022 to assess whether the pandemic impacted the number of lung cancer surgeries carried out by the Brazilian Unified Health System – the public and universal health system of Brazil. We presented the comparison between the periods under analysis (pre-pandemic and the different phases of the pandemic period) as a percentage of variation, obtained by the equation: [(number of surgeries in the period/number of surgeries in the immediately preceding period) − 1] * 100. This period's most frequent surgery types were segmentectomy, lobectomy, tumorectomy, and wedge resection. Overall, lung cancer surgeries were reduced by 22.2% during the first pandemic wave; this number nearly doubled in the country's poorer regions, the North and Northeast. As the subsequent pandemic waves emerged, lung cancer surgeries reduced even further, even though a complete recovery of cancer surgeries did not meet the previous receding of covid-19 cases and deaths. This observation holds for the country as a whole and each of its macro-regions. It also holds for Sao Paulo, the wealthiest Brazilian state, and Sao Paulo city, its largest metropolis (Table 1). In the third pandemic wave, a recovery to pre-pandemic levels seems to be taking shape (Fig. 1). However, considering the reductions in previous phases, this resumption in surgical production may partially reflect the assistance to repressed demands; it may be reckless to state that there is a return to normality. In addition, further investigations are necessary to understand whether chest CT scans indicated for certain suspected/confirmed cases of Covid-19 [[6]World Health Organization, Use of chest imaging in COVID-19. https://apps.who.int/iris/bitstream/handle/10665/332336/WHO-2019-nCoV-Clinical-Radiology_imaging-2020.1-eng.pdf?sequence=1&isAllowed=y, 2020 (accessed 10 March 2023).Google Scholar] have resulted in incidental lung cancer diagnoses.Table 1Surgeries in patients with lung cancer (C33-34 ICD10 codes) across covid-19 pandemic periods. Brazil National Health System, monthly averages, 2018–22.PeriodAll CountryNorth RegionNortheast RegionSoutheast RegionSouth RegionC. West RegionSão Paulo StateSão Paulo CityPre-pandemicJan-Dec 2018388.110.784.8154.0122.216.483.826.5Jan-Dec 2019418.911.397.7169.5124.715.892.627.6Jan-Mar 2020417.711.093.0171.3119.722.792.728.3Covid-19 1st waveApr-Jun 2020325.05.355.7134.7110.019.371.015.0Percent variation (1)–22.2%–51.5%–40.1%–21.4%–8.1%–14.7%–23.4%–47.1%Jul-Nov 2020399.814.086.2167.2113.818.681.021.8Covid-19 2nd waveDec 2020-Apr 2021347.28.287.0138.292.221.668.818.2Percent variation (1)–13.2%–41.4%+1.0%–17.3%–19.0%+16.1%–15.1%–16.5%May-Dec 2021438.39.997.1182.1120.828.492.127.5Covid-19 3rd waveJan-Mar 2022403.012.782.7168.0117.722.087.720.7Percent variation (1)–8.0%+28.3%–14.9%–7.8%–2.6%–22.5%–4.8%–24.8%Apr-Jul 2022463.814.5101.5184.8139.323.891.815.5(1) Percent variation of the number of surgeries during the beginning of each pandemic wave compared to the immediately preceding period. Open table in a new tab (1) Percent variation of the number of surgeries during the beginning of each pandemic wave compared to the immediately preceding period. Lung cancer has a poor prognosis and low survival rates [[7]Quaresma M. Coleman M.P. Rachet B. 40-year trends in an index of survival for all cancers combined and survival adjusted for age and sex for each cancer in England and Wales, 1971–2011: a population-based study.Lancet. 2016; 385: 1206-1218https://doi.org/10.1016/S0140-6736(14)61396-9Abstract Full Text Full Text PDF Scopus (296) Google Scholar]. We fear many other countries and cities may have faced an analogous situation during the pandemic, thus inducing an increase in cancer mortality in the short and mid-term. Cancer cannot wait for covid-19; lung cancer surgeries are not elective. We urge the professional field to assess the temporal relationship of lung cancer treatments across covid-19 phases both locally and regionally. Health surveillance is critical to uncover the problem; documenting it is an initial step toward its solution. Systematic and continuous data gathering and analysis of healthcare provision and utilization are instrumental in providing information to instruct health policy and planning.