Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19

Abstract

Background Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma. Methods A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. Results Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%. Conclusions Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

Impact of the COVID-19 pandemic on esophageal cancer resource allocation: a systematic review

“…A population-based modeling study addressing the estimated impacts of immediate vs. delayed surgical resection in a T1b esophageal adenocarcinoma was performed by Shipe et al Immediate esophagectomy resulted in an insignificant improvement in 5-year overall survival compared to delaying surgery by 3 months. However, in a sensitivity analysis, delayed esophagectomy (>3 months) resulted in a superior 5-year overall survival when the probability of COVID-19 infection was >7% ( 29 ). Sud et al modeled cancer progression during the pandemic as a result of pandemic-induced delays solely in surgical care.…”

“…Delayed access to endoscopy and subsequent greater disease severity at presentation have been suggested to be driving factors. Finally, various statistical analyses attempting to quantify the future health-related and economic costs of disruptions in EC care predicted significant decreases in survival and associated increased financial costs in the coming years ( 29 , 30 ).…”

The safety of esophageal cancer surgery during COVID-19

“…[ 19 ] Modeling the impact of delaying surgery for early EC in the era of COVID-19 showed that as the risk of infection with COVID-19 increased above 7%, delaying operations for 3 months has an improved long-term survival. [ 20 ] While other study showed that the EC time to surgery over 8 weeks is associated with lower survival. [ 21 ] So it is necessary to evaluate the safety of EC surgery during COVID-19.…”