Delayed Resection May Worsen Survival in Patients with Colorectal Cancer

Research published in the Journal of Gastrointestinal Surgery suggests that delayed resection of colorectal cancer worsens survival, though the evidence for worsened outcomes in pancreatic and gastric cancers is equivocal.¹

Given this finding with consideration to the coronavirus disease 2019 (COVID-19) pandemic, researchers recommended that resection should occur swiftly depending on the availability of hospital resources and local disease burden. However, when timely resection cannot occur, it was recommended that alternative therapies, including neoadjuvant treatment, should be considered.

“When we started this research, little knowledge existed about how long we could safely delay surgery for these cancers or how to prioritize which operations should occur first,” first author Scott C. Fligor, MD, a General Surgery resident at Beth Israel Deaconess Medical Center, said in a press release.² “In the context of the coronavirus pandemic, we were concerned that both surgeons and patients were forced to make decisions without a clear understanding of the risks of surgical delay."

In this systematic review of literature between 2005 and 2020, researchers investigated the impact of time to surgery on oncologic outcomes in patients with colorectal, pancreatic, and gastric cancer.

Overall, 1066 abstracts were screened for colorectal cancer and 43 papers were included. In primarily resected colon cancer, researchers found that a delay in resection over 30 to 40 days was associated with lower survival. In rectal cancer, time to surgery over 7 to 8 weeks following neoadjuvant therapy was correlated with decreased survival.

“In the setting of unprecedented healthcare demands expected to continue for months to years with an accumulating backlog of delayed surgical cases, it is critical to understand which cancer surgeries should be prioritized and which can be delayed with minimal risk,” the authors noted.

For pancreatic cancer, 394 abstracts were screened and 9 studies were included. Notably, 2 of the 9 studies demonstrated increased unexpected progression with delayed surgery over 30 days.

Of 633 abstracts screened for gastric cancer, 6 studies were included. Interestingly, none of the identified studies demonstrated worse survival with increased time to surgery.

“Surgical delay is associated with increased risk in some gastrointestinal malignancies,” said Fligor. “While every effort should be made to avoid surgical delay, the COVID-19 pandemic may make such delays unavoidable.”

Ultimately, the researchers indicated that early surgical management of cancer most often provides the best chance at curative treatment for patients with cancer, as delays invite further invasion, progression to unresectable disease, or metastasis. However, Fligor emphasized that delaying surgery does not necessarily mean delaying treatment.

“Providers should consider whether alternative therapies can help to minimize the risk of delay, such as extending a course of chemotherapy before surgery or initiating chemotherapy when surgery would normally occur first,” explained Fligor. “It is critical for patients to work with their health care team to create a safe plan for treatment during the pandemic. The right decision for each patient depends on several factors, including the type of cancer, treatments available, and the local burden of COVID-19.”

References:

1. Fligor SC, Wang S, Allar BG, et al. Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery. Journal of Gastrointestinal Surgery. doi: 10.1007/s11605-020-04712-5.

2. Study: surgical delay associated with increased risk in some gastrointestinal malignancies [news release]. Boston, Massachusetts. Published July 7, 2020. newswise.com/coronavirus/study-surgical-delay-associated-with-increased-risk-in-some-gastrointestinal-malignancies/?article_id=734277&sc=sphr&xy=10021790. Accessed July 29, 2020.