56 AJTCCM VOL. 30 NO. 2 2024
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Background. e COVID-19 pandemic had a signicant impact on health services globally. Cancer diagnosis and treatment was one of
the services most frequently reported to be disrupted. Several international studies showed a marked reduction in the number of new lung
cancer cases.
Objectives. To assess the impact of the COVID-19 pandemic on lung cancer diagnosis at a high-volume tertiary referral centre in South Africa.
Methods. A retrospective audit was conducted of all patients with primary lung cancer who were presented at the multidisciplinary oncology
meeting at Tygerberg Hospital, Cape Town, from January 2018 to December 2021, and the incidence of lung cancer was compared between
two cohorts: one prior to and one during the COVID-19 pandemic. We collected data on patient demographics, as well as performance
status. A combined panel staged all patients.
Results. During the COVID-19 pandemic there was a relative reduction of 46% in the frequency of lung cancer, from a mean of 25.6 cases
per month to 13.9. Patients referred during the COVID-19 pandemic had statistically better performance status (75.0% v. 25.0% with
performance status 0 - 2; p=0.01) and were more likely to have adenocarcinoma (49.7% v. 41.1%; p=0.02) than those referred before the
pandemic. e proportion of potentially curable lung cancer at presentation (i.e. stages I - IIIA) did not dier between the two cohorts.
Conclusion. e COVID-19 pandemic resulted in a substantial decrease in the number of new lung cancers diagnosed. Patients who were
diagnosed with lung cancer during the pandemic had better performance status and were more likely to have adenocarcinoma. No impact
on the proportion of potential curable disease was noted.
Keywords. COVID-19, lung cancer, staging.
Afr J Thoracic Crit Care Med 2024;30(2):e1031. https://doi.org/10.7196/AJTCCM.2024.v30i2.1031
Lung cancer is the second most commonly diagnosed cancer worldwide,
aer breast cancer.[1] According to the World Health Organization
(WHO), lung cancer resulted in 1.8 million deaths in 2020. It is also the
most common cause of cancer mortality in both males and females.[1]
e COVID-19 pandemic caused by SARS-CoV-2 had a signicant
impact on general health services.[2] In a pulse survey conducted
by the WHO in 2020, disruptions of essential health services were
reported by nearly all countries, especially lower-income countries.
[3] Cancer diagnosis and treatment was one of the services most
frequently reported to be disrupted globally.[3] Several international
studies showed a marked reduction in the number of new cases of lung
cancer. More patients were found to be symptomatic at presentation,
and more patients were found to have advanced disease.[4-7]
e objective of our study was to compare the incidence of lung cancer
between two cohorts, one prior to the COVID-19 pandemic and one
during the pandemic, at a high-volume tertiary referral centre in
South Africa (SA). We also compared the performance status, lung
cancer staging and potential cure rate of patients at presentation.
Methods
We retrospectively collected data on all patients with primary lung
cancer who were presented at the multidisciplinary oncology meeting
at Tygerberg Hospital during the period January 2018 - December
2021. Tygerberg Hospital is a 1 380-bed tertiary facility in Cape Town.
It is one of two referral centres in the city and renders tertiary service
to a population of ~3 million people.
e impact of the COVID-19 pandemic on lung cancer presentation
at a high-volume tertiary referral centre in South Africa
I Fredericks, MB ChB, FCP (SA) ; E M Irusen, MB ChB, FCP (SA), PhD; B W Allwood, MB ChB, FCP (SA), Cert Pulmonology (SA),
PhD; C F N Koegelenberg, MB ChB, MMed (Int Med), FCP (SA), FRCP, Cert Pulmonology (SA), PhD
Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
Corresponding author: I Fredericks (ilhaam.fredericks@gmail.com)
Study synopsis
What the study adds. Health services globally were substantially impacted by the COVID-19 pandemic. Cancer diagnosis and treatment
was one of the services most frequently reported to be disrupted. is study highlights the signicant impact of the COVID-19 pandemic
on lung cancer presentation in a high-volume tertiary hospital in South Africa.
Implications of the ndings. Lung cancer is known to have high mortality. e reduction in lung cancer presentation during the COVID-19
pandemic is likely to result in an increase in lung cancer-related morbidity and mortality over the next few years.
AJTCCM VOL. 30 NO. 2 2024 57
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We collected data on routine demographics such as age and gender,
along with patients’ performance status according to the Eastern
Cooperative Oncology Group (ECOG). All patients had access to
positron emission tomography-computed tomography, bronchoscopy
with endobronchial ultrasound-guided transbronchial needle
aspiration with rapid on-site evaluation, transthoracic imaging
(ultrasound or computed tomography)-guided biopsy, and related
diagnostic techniques that were performed at the discretion of the
treating doctors as per standard operating procedures. A combined
panel of at least a pulmonologist, a thoracic radiologist, a thoracic
surgeon, a specialist oncologist and a pathologist staged all patients
as per the 8th edition of the International Association for the Study of
Lung Cancer TNM staging system.[8] Stages IA - IIIA were considered
potentially curable at presentation.
Of the 4-year period, 27 months (January 2018 - March 2020) were
designated as prior to the COVID-19 pandemic and 21 months (April
2020 - December 2021) as during the pandemic. Of note is the fact
that access to bronchoscopy and other relevant staging modalities, as
well as pathology services, were deemed emergency services and not
halted at our institution during the pandemic.
We calculated and compared both the absolute number of lung
cancers diagnosed per time period and the staging of the lung cancers
(stage IA - IIIA v. IIIB - IVB) as categorical data. Basic descriptive
statistics such as means, proportions and standard deviations (SDs)
were calculated. Categorical data were analysed using the χ2 test
and continuous data using t-testing, with p<0.05 considered to be
signicant.
Ethical approval was obtained from the Health Research Ethics
Committee of Stellenbosch University (ref. no. S22/02/001_
COVID-19), and we were granted a waiver of informed consent owing
to the retrospective nature of the study.
Results
Over the 4-year period, a total of 982 patients were included in the study.
Of these, 690 (70%) formed the pre-pandemic group (27 months), with
a frequency of 25.6 per month. A total of 292 new lung cancer diagnoses
were made during the pandemic (21 months), equating to a frequency
of 13.9 per month, with a relative reduction of 46%.
e mean (SD) age of included participants was 59.6 (10.0) years,
and 606 (61.7%) were male (Table 1). There was no significant
dierence in age and sex distribution between the pre-pandemic
and pandemic groups, including the pandemic cohort with a larger
proportion of people living with HIV.
Overall, adenocarcinoma was significantly more common
during than before the pandemic (49.7% v. 41.1%; p=0.02). In the
pre-pandemic group, 4.4% had potentially curable lung cancer at
initial presentation (stages I - IIIA), compared with 3.4% during the
pandemic (p=0.59). Of note is the fact that patients had signicantly
better performance status (0 - 2) during the pandemic (p=0.01).
Discussion
During the COVID-19 pandemic, we observed a relative reduction of
46% in the incidence of lung cancer. Patients who were referred during
the pandemic had statistically signicantly better ECOG performance
Table 1. Demographics, cell types, stage and performance status for all lung cancer patients before and during the COVID-19 pandemic
All (N=982), n (%)*
Pre-pandemic
(n=690), n (%)*
During the pandemic
(n=292), n (%)* p-value
Demographics
Age (years), mean (SD) 59.6 (10.0) 59.9 (9.9) 59.1 (10.1) 0.23
Sex (male) 606 (61.7) 423 (61.3) 183 (62.7) 0.71
HIV infected 61 (6.2) 36 (5.5) 25 (8.6) 0.06
Cell type
NSCLC
Adenocarcinoma 429 (43.7) 284 (41.1) 145 (49.7) 0.02
Squamous cell carcinoma 263 (26.8) 189 (27.4) 74 (25.3) 0.53
Poorly or undierentiated 164 (16.7) 122 (17.7) 42 (14.4) 0.22
SCLC 126 (12.8) 95 (13.8) 31 (10.6) 0.21
Stage 0.59†
I 8 (0.8) 8 (1.2) 0 (0.0)
II 6 (0.6) 2 (0.3) 4 (104)
IIIA 26 (2.7) 20 (2.9) 6 (2.0)
IIIB 71 (7.2) 53 (7.7) 18 (6.2)
IIIC 118 (12.0) 89 (12.9) 29 (9.9)
IVA 433 (44.1) 299 (43.3) 134 (45.9)
IVB 320 (32.6) 219 (31.7) 101 (34.6)
ECOG performance status 0.01
0 - 2 679 (69.1) 460 (66.7) 219 (75.0)
3 - 4 303 (30.9) 230 (33.3) 73 (25.0)
SD = standard deviation; NSCLC = non-small cell lung cancer; SCLC = small cell lung cancer; ECOG = Eastern Cooperative Oncology Group.
*Except where otherwise indicated.
†Stages I - IIIA v. IIIB – IVB.
58 AJTCCM VOL. 30 NO. 2 2024
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status (75.0% v. 25.0% with performance status 0 - 2; p=0.01) and
were more likely to have adenocarcinoma (49.7% v. 41.1%; p=0.02).
However, the potential cure rate at presentation did not dier between
the two cohorts.
e reduction observed in new lung cancer diagnoses is very similar
to the results reported by other investigators from our institution, who
reported a 36.2% decline in the number of all new cancers diagnosed
during the rst wave of the COVID-19 pandemic.[9] ese authors
noted an overall reduction in the cytopathological diagnosis of cancer of
61.1%. Substantial declines were seen for prostate (58.2%), oesophageal
(44.1%), breast (32.9%), gastric (32.6%) and colorectal cancer (29.2%).
e smallest decline was for cervical cancer (7%).[9] A study from Spain
also reported a 38% reduction in new lung cancer cases.[4]
In a pulse survey conducted by the WHO in 2020,[3] disruptions
of essential health services were reported by nearly all countries,
especially lower-income countries. e disruptions were caused by
a combination of factors including lockdowns impeding access to
healthcare, nancial diculties during lockdowns, cancellation of
elective services, reductions in attendance of outpatient services, sta
redeployment to provide COVID-19 relief, unavailability of services
owing to closures of health facilities or health services, and supply-
chain diculties. Cancer diagnosis and treatment was one of the
services most frequently reported to be disrupted globally.[3] At our
institution, pulmonology services were markedly de-escalated owing
to the need to use sta and other hospital resources in the COVID-19
response. Patients did not come to hospital because they were afraid
of contracting the disease. Outpatient services were also de-escalated.
Furthermore, COVID-19 may have caused increased mortality in
patients with lung cancer prior to presentation.
e rate of potentially curable cancer (stages I - IIIA) was similar
in the two groups, with no statistically signicant dierence (p=0.59).
is nding is in contrast to some international studies that showed
a reduction in early-stage lung cancer during the COVID pandemic.
[6] e most likely explanation for this observation internationally
is the suspension of lung cancer screening in the developed world
during the start of the pandemic.[7] SA did not have a lung cancer
screening programme at the time, and patients historically present to
our institution late in the disease course.
Our study showed that patients who presented during the
COVID-19 pandemic had better performance status than those who
presented pre-pandemic. e most plausible explanation for this
nding is selection bias, as referring doctors were arguably more
likely to refer patients who could benet from oncology services. It
contrasts with international data, where most countries found patients
who presented during the pandemic to be more symptomatic.[4]
Adenocarcinoma is well known to be the predominant tissue
type in new lung cancer diagnoses, both globally and locally.[10]
However, the statistically signicant increase in the proportion of
adenocarcinoma during the pandemic was an unexpected nding.
One possible explanation is that lung cancer in younger adults tends
to be adenocarcinoma and to be stage IV at presentation, which may
have contributed to a selection bias.[11]
One of the strengths of our study is that it was performed in a
high-volume tertiary referral centre with access to all relevant staging
and diagnostic modalities. Potential limitations may include major
selection bias during the peaks of the pandemic, when patients with
perceived advanced disease or with very poor performance status
were considered for palliation without referral.
Conclusion
During the COVID-19 pandemic there was a relative reduction
of 46% in the incidence of lung cancer observed in a high-volume
tertiary referral centre, and patients who were referred and diagnosed
with lung cancer had statistically better performance status and were
more likely to have adenocarcinoma than those in the pre-pandemic
period. No impact on the proportion of potentially curable disease
was noted.
Declaration. EMI, BWA and CFNK are members of the editorial
board. The research for this study was done in partial fulfilment of the
requirements for IF’s MMed (Int Med) degree at Stellenbosch
University.
Acknowledgements. None.
Author contributions. CFNK and IF conceived and designed the study;
IF was responsible for data collection; all authors were involved with
analysis and interpretation of data; IF drafted the manuscript, which was
critically revised by all authors; and all authors approved the final version.
Funding. None.
Conflicts of interest. None.
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Received 1 May 2023. Accepted 25 March 2024. Published 4 July 2024.
