The impact of the COVID-19 pandemic on cervical cancer disease severity

Background: The COVID-19 (C19) pandemic is reported to be associated with decreases in cervical cancer screening, diagnostic procedures, number of patients receiving treatment, and treatment delays/interruptions, leading to increased disease progression compared to pre-C19. This study aims to investigate if an increase in squamous cell cervical cancer (SCCC) disease severity occurred and evaluate changes in time to treatment during C19. Methods: This retrospective study analyzed the National Cancer Database from 2018–2019 (pre-C19) and 2020–2021 (C19) for patients with SCCC. Descriptive statistics were utilized to compare American Joint Committee on Cancer (AJCC) tumor node metastasis (TNM) stage distribution (correlating with 2018 International Federation of Gynecology and Obstetrics (FIGO) IA1–IVB), time from diagnosis to treatment, and treatment types received between pre-C19 and C19. Results: A total of 11,455 SCCC patients pre-C19 were compared to 10,155 during C19. During C19, there were fewer patients with early-stage disease (FIGO IA1–IIA2) (44.1% pre-C19 vs. 38.1% C19), more with locally advanced disease (FIGO IIB–IVA) (42.8% pre-C19 vs. 47.8% C19), and more with metastatic disease (FIGO IVB) (13.0% pre-C19 vs. 14.1% C19) (p < 0.001). Time to treatment (p = 0.10) and surgery (p = 0.29) did not differ significantly. There were significantly fewer surgeries during C19 (34.1% pre-C19 vs. 31.8% C19, p < 0.001). There was no statistical difference in age (p = 0.12), Charlson Comorbidity Index scores (p = 0.23), receipt of chemotherapy (68.8% pre-C19 vs. 69.9% C19, p = 0.09), or radiation (29.9% pre-C19 vs. 28.8% C19, p = 0.10) during C19. Conclusions: Despite no significant differences in time to treatment and surgery, there was a higher incidence of more advanced SCCC during the C19 pandemic. This may be explained by decreased routine examination and diagnostic follow-up. Further data are awaited to characterize the long-term survival effects of C19 on SCCC patients.

Uterine cervical neoplasms; Carcinoma; Squamous cell; Early detection of cancer; COVID-19; Pandemics

[1] CDC. CDC museum COVID-19 timeline. 2024. Available at: https://www.cdc.gov/museum/timeline/covid19.html#:~:text=March%2011%2C%202020,declares%20COVID%2D19%20a%20pandemic (Accessed: 20 October 2024).

[2] Rucinska M, Nawrocki S. COVID-19 pandemic: impact on cancer patients. International Journal of Environmental Research and Public Health. 2022; 19: 12470.

[3] COVIDSurg Collaborative. Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study. The Lancet Oncology. 2021; 22: 1507–1517.

[4] Fedeli U, Barbiellini Amidei C, Han X, Jemal A. Changes in cancer-related mortality during the COVID-19 pandemic in the United States. Journal of the National Cancer Institute. 2024; 116: 167–169.

[5] Patt D, Gordan L, Diaz M, Okon T, Grady L, Harmison M, et al. Impact of COVID-19 on cancer care: how the pandemic is delaying cancer diagnosis and treatment for American seniors. JCO Clinical Cancer Informatics. 2020; 4: 1059–1071.

[6] Mallouh M, Linshaw D, Barton B, De La Cruz G, Dinh K, LaFemina J, et al. Changes in stage at presentation among lung and breast cancer patients during the COVID-19 pandemic. Journal of the American College of Surgeons. 2023; 236: 1164–1170.

[7] Tonneson JE, Hoskin TL, Day CN, Durgan DM, Dilaveri CA, Boughey JC. Impact of the COVID-19 pandemic on breast cancer stage at diagnosis, presentation, and patient management. Annals of Surgical Oncology. 2022; 29: 2231–2239.

[8] Sawaya GF, Holt HK, Lamar R, Perron-Burdick M, Smith-McCune K. Prioritizing cervical cancer screening services during the COVID-19 pandemic: response of an academic medical center and a public safety net hospital in California. Preventive Medicine. 2021; 151: 106569.

[9] ACOG. COVID-19, gynecologist visits, and telehealth: answers from Ob-Gyns. 2022. Available at: https://www.acog.org/womens-health/faqs/coronavirus-covid-19-and-womens-health-care (Accessed: 23 September 2024).

[10] Andrzejczak A, Zarlok E, Osowiecka K, Rucinska M. Execution of the breast cancer and cervical cancer screening programs in Poland in the first period of restrictions introduced due to the COVID-19 pandemic. General Medicine and Health Sciences. 2021; 27: 428–434.

[11] de Pelsemaeker MC, Guiot Y, Vanderveken J, Galant C, Van Bockstal MR. The impact of the COVID-19 pandemic and the associated Belgian governmental measures on cancer screening, surgical pathology and cytopathology. Pathobiology. 2021; 88: 46–55.

[12] The Lancet Oncology. COVID-19 and the US health insurance conundrum. The Lancet Oncology. 2020; 21: 733.

[13] National Cancer Database. American college of surgeons. 2024. Available at: https://www.facs.org/quality-programs/cancer/ncdb (Accessed: 04 December 2024.)

[14] Mallin K, Browner A, Palis B, Gay G, McCabe R, Nogueira L, et al. Incident cases captured in the National Cancer Database compared with those in U.S. population based central cancer registries in 2012–2014. Annals of Surgical Oncology. 2019; 26: 1604–1612.

[15] Toboni MD, Cohen A, Gentry ZL, Ostby SA, Wang Z, Bae S, et al. Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a national cancer database study. International Journal of Gynecological Cancer. 2022; 32: 724–731.

[16] Marcus JZ, Cason P, Downs LS Jr, Einstein MH, Flowers L. The ASCCP cervical cancer screening task force endorsement and opinion on the american cancer society updated cervical cancer screening guidelines. Journal of Lower Genital Tract Disease. 2021; 25: 187–191.

[17] Burmeister CA, Khan SF, Schäfer G, Mbatani N, Adams T, Moodley J, et al. Cervical cancer therapies: current challenges and future perspectives. Tumour Virus Research. 2022; 13: 200238.

[18] Kousar K, Ahmad T, Naseer F, Kakar S, Anjum S. Review article: immune landscape and immunotherapy options in cervical carcinoma. Cancers. 2022; 14: 4458.

[19] Center for Drug Evaluation and Research. FDA approves pembrolizumab combination for the first-line treatment of cervical cancer. 2021. Available at: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-pembrolizumab-combination-first-line-treatment-cervical-cancer#:~:text=On%20October%2013%2C2021%2C%20the,by%20an%20FDA%2Dapproved%20test (Accessed: 09 November 2024).

[20] Han X, Yang NN, Nogueira L, Jiang C, Wagle NS, Zhao J, et al. Changes in cancer diagnoses and stage distribution during the first year of the COVID-19 pandemic in the USA: a cross-sectional nationwide assessment. The Lancet Oncology. 2023; 24: 855–867.

[21] Komatsu H, Ikeda Y, Kawana K, Nagase S, Yoshino K, Yamagami W, et al. Obstetrics TCOGOOTJSO, gynecology. Impact of COVID-19 on gynecological cancer incidence: a large cohort study in Japan. International Journal of Clinical Oncology. 2024; 29: 72–77.

[22] Wickenheisser NE, Dillon M, Broadwater G, Zacherl K, Bixel K, Levine M, et al. Radical hysterectomy case volume and cervical cancer treatment in the era of COVID-19: a multi-site analysis of national cancer institute-designated comprehensive cancer centers. Gynecologic Oncology. 2023; 179: 70–78.

[23] Chapman GC, Smrz SA, Gordon JC, Lynam SK, Strohl AE, Ferguson LA, et al. Gynecologic cancer care in the first year of the COVID-19 pandemic. Gynecologic Oncology. 2023; 178: 138–144.

[24] Moore R, Purvis RS, Hallgren E, Reece S, Padilla-Ramos A, Gurel-Headley M, et al. “I am hesitant to visit the doctor unless absolutely necessary”: a qualitative study of delayed care, avoidance of care, and telehealth experiences during the COVID-19 pandemic. Medicine. 2022; 101: e29439.

[25] Czeisler MÉ, Marynak K, Clarke KEN, Salah Z, Shakya I, Thierry JM, et al. Delay or avoidance of medical care because of COVID-19-related concerns—United States, June 2020. Morbidity and Mortality Weekly Report. 2020; 69: 1250–1257.