Society for Surgery of the Alimentary Tract
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Gordana Rasic*1,2, Brendin R. Beaulieu-Jones1,2, Sophie H. Chung1,2, Kelsey S. Romatoski1,2, Kelly Kenzik2,1, Sing Chau Ng2,1, Jennifer F. Tseng1,2, Teviah Sachs1,2
1Department of Surgery, Boston Medical Center, Boston, MA; 2Boston University School of Medicine, Boston, MA

Introduction: The coronavirus disease 2019 (COVID-19) pandemic placed great strain on the healthcare system, with documented delay of oncologic care access and delivery in several cancers. However, little is known regarding the effects of the pandemic in the management of hepatocellular carcinoma (HCC). Our study sought to evaluate the effect of the COVID-19 pandemic on time to treatment initiation (TTI) in HCC and to elucidate factors predictive of increased treatment intervals.
Methods: This retrospective cohort study queried the National Cancer Database for patients who were diagnosed with clinical stages I-IV HCC (2017 – 2020). Patients were categorized based on their year of diagnosis as "Pre-COVID" (2017-2019) and "COVID" (2020). Categorical variables were compared by chi-square analysis. TTI based on clinical stage and type of treatment first-received were compared by the Mann-Whitney U test. A negative binomial regression model was used to evaluate factors predictive of increased TTI, defined as days from surgery to first curative therapy.
Results: Of 23,922 patients identified with HCC who underwent treatment, 18,673 (78.1%) patients were diagnosed during the 3 analyzed pre-COVID years, whereas 5,249 (21.9%) during the 2020 COVID year. Patients diagnosed during the COVID year were older (53.0% vs. 46.9%, p<0.0001), covered by Medicare (55.4% vs. 51.6%, p< 0.0001), and more often diagnosed stage IV (16.9% vs. 13.9%, p<0.0001). Median TTI for any first line treatment modality was slightly shorter during the COVID year compared to those of Pre-COVID (49 vs. 51d; p<0.0001), most notably in time to ablation (52 vs. 55d; p=0.0238), systemic therapy (42 vs. 47d; p<0.0001), and radiation (60 vs. 62d; p=0.0177), but not surgery (41 vs. 41d; p=0.6888). In a multivariate analysis controlling for pre-COVID vs COVID years of diagnosis, Black race, Medicare coverage, and uninsured/Medicaid/other government status were associated with increased TTI by factors of 1.068 (95% CI: 1.033-1.104; p=0.0001), 1.037 (95% CI: 1.007-1.068; p=0.0144), and 1.080 (95% CI: 1.047-1.115, p<0.0001), respectively. While patients managed by radiation therapy demonstrated an increased TTI (1.220; 95% CI: 1.173-1.268, p<0.0001), overall TTI was decreased for patients diagnosed during the 2020 COVID year (0.940; 95% CI, 0.916-0.965, p<0.0001).
Conclusion: For patients diagnosed with HCC during the first COVID year of 2020, no clinically significant differences were appreciated in the TTI of patients with HCC. This observation must be understood in the context of potential underdiagnosis of HCC. However, vulnerable populations were in contradistinction more likely to have increased TTI. Time will allow us to better understand the future effects of this pandemic which has been shown to disproportionately affect patients of underserved populations.

Stage at diagnosis and treatment received compared between the Pre-COVID and COVID periods

Time to treatment initiation based on the first-received treatment modality compared between the Pre-COVID and COVID periods

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