How did COVID-19 influence use of neoadjuvant therapy before surgery for patients with HPB cancers?

Abstract

Background: The COVID-19 pandemic caused widespread disruption of the United States (US) healthcare system. Medical resources were rationed, and healthcare organizations worked to prevent hospitalizations in both healthy and high-risk patients. Numerous surgical specialties decreased elective operations during the peak of the pandemic, but surgical oncologists were faced with balancing the risks of oncologic progression with exposing immunosuppressed patients to nosocomial COVID-19. In recent years neoadjuvant therapy (NAT) has been increasingly utilized in pancreatic and colorectal malignancies. However, no analyses have determined whether these practice patterns were disrupted by the pandemic. Thus, the aims of this study were to evaluate the effect of COVID-19 on the volume of operations for pancreatic, primary hepatic, and secondary hepatic malignancies in patients who had undergone NAT. Methods: The Vizient Clinical Database was queried for national data from participating hospitals, including 97% of academic medical centers and over 100 oncologic hospitals. These institutions perform the majority of pancreatic and hepatic surgery in America. Data were obtained for 12 months before (March 2019 – February 2020) and 27 months during (April 2020 – June 2022) the COVID-19 pandemic. Patients who underwent neoadjuvant therapy (chemotherapy or immunotherapy) followed by major operations for pancreatic, primary hepatic (hepatocellular carcinoma and intrahepatic cholangiocarcinoma), and secondary hepatic (colorectal metastases) malignancies were included. Case volume trends were compared before and during the pandemic using QI Macros Control Charts. Mean comparison of case volume before and during the pandemic was performed using Student’s t Test and Wilcoxon Rank Sum Test in R (Version 4.2.1). Results: Over the 40-month study period, 6,936 patients received NAT and underwent surgery; 5,594 patients (80.7%) had pancreatic operations, 685 patients (9.9%) underwent surgery for primary hepatic malignancies, and 657 patients (9.5%) had hepatic operations for metastatic colorectal cancer. Pancreatic operations for patients who received NAT steadily increased throughout the study period (Figure A) while hepatic operations for metastatic colorectal cancer after NAT (Figure C) transiently increased 20 months into the pandemic. Operations for primary hepatic malignancies in patients who received NAT were unaffected by the pandemic (Figure B). These findings were confirmed with the average monthly case volume for pancreatic operations increasing during COVID-19 (126 vs 146, p< 0.001). No statistically significant changes were noted in the mean monthly operative volume for primary hepatic malignancies (17 vs 17, p=0.809) or for secondary hepatic malignancies following NAT (15 vs 17, p=0.213). Conclusion: Despite the pandemic, the number of oncologic operations for pancreatic cancer following neoadjuvant therapy (NAT) increased over time, continuing a pre-pandemic trend. A transient increase in oncologic operations for secondary hepatic malignancies following NAT was observed late in the pandemic. The volume of operations following NAT for primary hepatic malignancies was unaffected by the pandemic. The utilization of NAT for operative hepato-pancreato-biliary malignancies was not altered by the COVID-19 pandemic.