Abstract / Summary
Background: COVID-19 negatively impacted cancer diagnostic and treatment services worldwide. These challenges were further compounded in low- and middle-income countries, where longstanding resource constraints limited the capacity to maintain standard treatment pathways. We aimed to assess the impact of COVID-19 on (i) stage at diagnosis and time intervals from symptom recognition to a pathological confirmed breast cancer (BC) diagnosis and (ii) treatment initiation at two academic hospitals in Johannesburg; Chris Hani Baragwaneth Academic Hospital (Site 1) and Charlotte Maxeke Johannesburg Academic Hospital (Site 2).
Methods: We compared the proportion of BC cases diagnosed at a late stage (stage III/IV) and median time intervals of pre-contact (T1), diagnostic (T2) and treatment initiation following diagnosis (T3) pre, during and post COVID-19 among 2522 women. Using cumulative Kaplan-Meier time-to-event analysis we assessed the proportions of women achieving internationally benchmarked intervals.
Results: Late-stage BC diagnoses increased during COVID-19 but subsequently recovered, with pre-, during-; and post-COVID-19 percentages, respectively, of 50%, 60% and 53% at Site 1 and 63%, 69% and 55% at Site 2. Compared to pre-COVID-19, at Site 1 the T1 interval increased during and post COVID-19 (from 0.8 (IQR: 0.3-4.0) months to 1.0 (IQR: 0.5-6.0) and 2.0 (IQR: 0.5-6.0) post COVID-19 (P < 0.001), respectively); there were no significant T1 changes at Site 2. Delays more than 3 months were associated with late-stage diagnosis. T2 intervals did not differ significantly across COVID-19 periods at both sites. The treatment interval (T3) at Site 1increased from a pre-COVID-19 median of 1.6 (IQR: 1.0-2.6) to 2.0 (IQR: 1.2-4.3) during COVID-19 and remained at 2.0 (IQR: 1.1-4.0) post COVID-19 (P < 0.001); at Site 2 an increase also occurred during COVID-19 but was not significant. Internationally benchmarked staging and timeliness targets were never achieved.
Conclusions: The already high prevalence of late-stage at diagnosis increased further during the COVID-19 pandemic with evidence of recovery at both sites in the post COVID-19 period. Treatment initiation delays increased and surgery volumes decreased during the pandemic and did not recover to pre-pandemic levels. Our study shows current cancer human and facility resources are insufficient to manage the steadily increasing BC burden in Johannesburg, South Africa.