Impact of the COVID-19 pandemic and related control measures on cancer diagnosis in Catalonia: a time-series analysis of primary care electronic health records covering about five million people

  1. Ermengol Coma
  2. Carolina Guiriguet
  3. Nuria Mora
  4. Mercè Marzo-Castillejo
  5. Mencia Benítez
  6. Leonardo Méndez-Boo
  7. Francesc Fina
  8. Mireia Fàbregas
  9. Albert Mercadé
  10. Manuel Medina

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Abstract

Cancer care has been disrupted by the response of health systems to the COVID-19 pandemic, especially during lockdowns. The objective of our study is to evaluate the impact of the pandemic on the incidence of cancer diagnoses in primary care.

Design

Time-series study of malignant neoplasms and diagnostic procedures, using data from the primary care electronic health records from January 2014 to September 2020.

Setting

Primary care, Catalonia, Spain.

Participants

People older than 14 years and assigned in one of the primary care practices of the Catalan Institute of Health with a new diagnosis of malignant neoplasm.

Main outcome measures

We obtained the monthly expected incidence of malignant neoplasms using a temporary regression, where the response variable was the incidence of cancer from 2014 to 2018 and the adjustment variables were the trend and seasonality of the time series. Excess or lack of malignant neoplasms was defined as the number of observed minus expected cases, globally and stratified by sex, age, type of cancer and socioeconomic status.

Results

Between March and September 2020 we observed 8766 (95% CI 4135 to 13 397) fewer malignant neoplasm diagnoses, representing a reduction of 34% (95% CI 19.5% to 44.1%) compared with the expected. This underdiagnosis was greater in individuals aged older than 64 years, men and in some types of cancers (skin, colorectal, prostate). Although the reduction was predominantly focused during the lockdown, expected figures have not yet been reached (40.5% reduction during the lockdown and 24.3% reduction after that).

Conclusions

Reduction in cancer incidence has been observed during and after the lockdown. Urgent policy interventions are necessary to mitigate the indirect effects of the COVID-19 pandemic and related control measures on other diseases and some strategies must be designed in order to reduce the underdiagnosis of cancer.

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  1. Version published to 10.1136/bmjopen-2020-047567
  2. ScreenIT

    SciScore for 10.1101/2020.11.26.20239202: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    We categorised the MEDEA deprivation index into quartiles where 1st and 4th quartiles are least and most deprived areas, respectively.
    MEDEA
    suggested: (MEDEA, RRID:SCR_013356)

    Results from OddPub: Thank you for sharing your code and data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has some limitations. Firstly, we performed a time-series study with ecological data, but this approach does not allow to ensure a causal correlation between reduction of the incidence of malignant neoplasm and COVID-19 pandemic, although the reduction in the observed data around the start of the state of the alarm in March 2020 is clear. Secondly, as COVID-19 striked hard Spain with an excess of 44,000 deaths [49], some can argue that part of the reduction of the incidence of malignant neoplasms could be linked to the harvesting effect where some patients that could have been diagnosed had deceased. Even so, we observed a defect of the incidence of cancer in all age groups while the excess of deaths caused by COVID-19 was mostly in old people [49]. Despite the limitations, this study also has strengths. The data used were obtained from primary care EHR and are of good quality. Several studies have used the Catalan EHR to do useful research in real-world conditions [29, 50]. Moreover, our estimation used data from five years and we validated our method with 2019 diagnoses, where we didn’t find any excess or reduction of the incidence of cancer, strengthening our findings in 2020. In addition, our analysis extends the first wave of COVID-19-related effects and lasted for seven months in contrast to other studies focused on lockdown period only. We also assessed the socioeconomic differences, identifying the most affected areas that should be a priority during the fol...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  3. Version published to 10.1101/2020.11.26.20239202v1 on medRxiv