Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov , NCT04384926 . Findings Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays. Interpretation Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include...

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Aim:Little is known about the delivery of colorectal cancer treatment in India and its associated costs. The aim of this study is to identify financial and nonfinancial barriers to adherence to colorectal cancer treatment in India.Method: CROCODILE is a mixed-methods study with a quantitative and a qualitative workstream. The quantitative workstream will be a prospective cohort study to assess treatment adherence and catastrophic expenditure rates among patients with colorectal cancer in India. Consecutive newly diagnosed patients with histopathologically proven colorectal cancer from five tertiary hospitals in India will be included. Catastrophic expenditure will be defined as a treatment cost higher than 40% of nonsubsistence annual household income. Treatment costs will include medical, nonmedical and indirect expenses. Income assessment will be compared between three methods: patientreported income, the International Wealth Index and the Gapminder tool. The qualitative workstream will explore the views and experiences of colorectal cancer patients and professionals about barriers to and facilitators for treatment adherence. Individual semistructured interviews with three to five patients and cancer care professionals in each centre will be performed. An analytical framework will be developed to perform the analysis, through a combined approach (deductive and inductive). The results will be triangulated with the quantitative workstream for mutual knowledge enrichment. Conclusion:The CROCODILE study will identify barriers to and facilitators for colorectal cancer delivery in India, influencing research and policy decisions. It will explore the feasibility of collecting data on patient-level costs and income to inform future economic evaluations in cancer and surgical care.