In a study published this past week in JAMA Network Open, Eugene Cone, MD, and colleagues found that a longer time to treatment initiation negatively impacts survival in patients with breast, prostate, colon, and lung cancers, a finding that is particularly relevant with the deferral of treatment during the COVID-19 pandemic. In this interview, Dr. Cone, a clinical fellow in surgery at Massachusetts General Hospital, speaks with i3 Health about the significance of these results and shares advice for clinicians regarding the prioritization of cancer treatment during the pandemic.
What prompted you to investigate the association between time to treatment initiation and survival in patients with common cancers?
Eugene Cone, MD: For patients with cancer, the optimal timing of both diagnosis and treatment was very unclear in the early days of the COVID-19 crisis. We as clinicians were forced to balance the competing risks of COVID infection and exposure if patients come into the clinic or the hospital against the morbidity and potential mortality of undiagnosed or untreated cancer. It was really an unanswered question: how long is it appropriate to defer diagnosis or treatment of these cancers? Given that most of the guidelines are based on expert consensus—which basically means that a lot of very experienced oncologists and other clinicians get together and think about what makes sense in terms of science—there's no direct, applicable data to answer that question. It seems like a good area to try to establish some more data-based guidelines.
What is the significance of your study's findings?
Dr. Cone: The first takeaway of our study is that there is a limit as to how long cancer treatment can be safely deferred. We weren't able to look at how long diagnosis can be deferred, because that was outside the scope of our study, but that's also a very interesting and unanswered question at this point. With clinics being closed or overwhelmed due to COVID, we are quite concerned that patients' diagnoses are being delayed, as well as routine screening measures. From a treatment standpoint, though, there is a limit to the safe deferral of treatment, and it's a lot sooner than we expected for a lot of cancers.
For example, prostate cancer is thought of as a slow-growing cancer, something for which patients can wait six or even twelve months to begin treatment, even for those with high-risk disease. That's what previous meta-analyses and review papers have published, and that's what guidelines around COVID-related deferrals of treatment reflected: that treatment could be deferred for up to six months. What we found was that there was actually increased mortality, even for intermediate-risk prostate cancer, with delays as short as 60–120 days after diagnosis. So takeaway number one is that there's a limit to how long treatment can be deferred. Takeaway number two is that the time period in which it's appropriate to delay treatment is shorter than we thought. For the higher-risk cancers like colon cancer and non-small cell lung cancer (NSCLC), we found that really no amount of deferral was safe.
To what do you attribute your finding that patients with colon cancer and NSCLC experienced the highest mortality?
Dr. Cone: The main factor is just that out of the cancers that we studied, these are the ones associated with the highest mortality in general. Since the overall mortality is higher, the effects of any change are going to be higher as well. I don't think it's necessarily anything intrinsic to COVID-related deferrals; these are just more lethal cancers, which makes it even more imperative that we do not delay treatment.
In light of your results, what changes need to made regarding treatment deferrals during the COVID-19 pandemic?
Dr. Cone: Based on the basket of cancers that we evaluated, it really calls into question whether any amount of deferral is truly safe, from an oncologic perspective, for any cancer. The only cancer for which we found no risk associated with deferred treatment was favorable-risk prostate cancer, and we already know that the majority of favorable-risk prostate cancers don't actually require treatment because they don't really metastasize. For cancers that we know have a metastatic and oncologic risk, our study asks the question of whether any treatment can be safely deferred. From our personal experience, we did see some upstaging and worsening of cancer outcomes after the treatment deferrals associated with the first wave of the pandemic. With the second wave, it's incumbent upon us to figure out a way to safely arrange for cancer surgeries, radiation, and chemotherapy. There are plenty of elective conditions that we could probably safely defer treatment for, but I don't think cancer is one of them.
About Dr. Cone
Eugene Cone, MD, is a Clinical Fellow in Surgery at Massachusetts General Hospital and a Fellow in Urologic Oncology at Harvard School of Medicine. He also serves as Chair Elect of the American Urological Association Residents and Fellows Committee. Dr. Cone has authored or coauthored numerous publications in peer-reviewed journals.
For More Information
Cone EB, Marchese M, Paciotti M, et al (2020). Assessment of time-to-treatment initiation and survival in a cohort of patients with common cancers. JAMA Netw Open, 3(12):e20130072. DOI:10.1001/jamanetworkopen.2020.30072
Transcript edited for clarity. Any views expressed above the speaker's own and do not necessarily represent those of i3 Health.