Risk factors and clinical outcomes of systemic cancer treatment delays in Filipino patients with solid tumor malignancy during the COVID‐19 pandemic: A single tertiary center study

Abstract Background Cancer care during the Covid‐19 pandemic has been challenging especially in a developing country such as the Philippines. Oncologists were advised to prioritize chemotherapy based on the absolute benefit that the patient may receive, which outbalances the risks of Covid‐19 infection. The results of this study will allow re‐examination of how to approach cancer care during the pandemic and ultimately, help optimize treatment recommendations during this crisis. Aim This study described the factors contributing to treatment delays during the pandemic and their impact on disease progression. Materials and results This retrospective cohort study was done in St. Luke's Medical Center, a private tertiary healthcare institution based in Metro Manila, Philippines, composed of two facilities in Quezon City and Global City. Patients with solid malignancy with ongoing systemic cancer treatment prior to the peak of the pandemic were identified. Clinical characteristics and treatment data were compared between those with delayed and continued treatments. Multivariate analysis was done to determine factors for treatment delays and association of delays with disease progression and Covid‐19 infection. Of the 111 patients, 33% experienced treatment delays and 67% continued treatment during the pandemic. There was a higher percentage of patients on palliative intent who underwent treatment delay, and 64% of delays were due to logistic difficulties. Treatment delays were significantly associated with disease progression (p < .0001). There was no evidence of association between delay or continuation of treatment and risk of Covid‐19 infection. Conclusions There was no difference in Covid‐19 infection between those who delayed and continued treatment during the pandemic; however, treatment delays were associated with a higher incidence of disease progression. Our findings suggest that the risks of cancer progression due to treatment delays exceed the risks of Covid‐19 infection in cancer patients implying that beneficial treatment should not be delayed as much as possible. Logistic hindrances were also identified as the most common cause of treatment delay among Filipino patients, suggesting that efforts should be focused into assistance programs that will mitigate these barriers to ensure continuity of cancer care services during the pandemic.

focused into assistance programs that will mitigate these barriers to ensure continuity of cancer care services during the pandemic. altering the chemotherapy schedule so that fewer hospital visits are needed. [4][5][6] These recommended treatment delays, however, may lead to significant complications that may impact cancer outcomes such as disease progression, relapse, and mortality. It has been documented that delays in chemotherapy, in general, can have an adverse impact on survival. 7  It is important to characterize these pandemic-related treatment delays to help cancer providers and healthcare systems develop effective strategies to manage cases during the current pandemic wave, subsequent waves, and future disasters. This study described the incidence of cancer treatment delays in cancer patients, the different factors that may have contributed to these delays and its impact on cancer-related morbidity and mortality.
This study also compared the rates of Covid-19 infection among those who continued receiving treatment and those who did not.
Recommendation on cancer care during a pandemic is still evolving and there is no "one size fits all" approach. The results of this study will allow re-examination of how to approach cancer care during the pandemic and ultimately, help optimize treatment recommendations during this crisis.

| Study definitions
Systemic cancer treatment includes cytotoxic chemotherapy, hormonal therapy, targeted therapy, and immunotherapy. Monotherapy includes treatment with only one type of agent, while combination therapy means treatment with more than one agent of systemic chemotherapy. Treatment delay was defined as discontinuation for more with risk of treatment delay between other cancer types, type of treatment, type of regimen, and indication for treatment.
In those who had treatment delays, majority had reasons related to logistic difficulties (Table 4). Logistics-related reasons, which included travel restrictions, lockdown policies, and closure of chemotherapy centers, were significantly associated with increased incidence of treatment delays (OR 35.36, 95% 11.74-106.47), p < .0001).
A total of 39.64% of patients had disease progression (Table 5).
There was a significant difference (<.0001) between rates of disease progression between patients who had treatment delays and continu-  According to a recent report on the impact of Covid-19 and national income, there was at least a 10% decline in income across the entire income distribution and a record-high unemployment rate of 18%, meaning that about 7.3 million Filipinos had lost their jobs. 23 Most of the included patients in this study were from the mid-to high-income sector, which may signify that they were also vulnerable to treatment delays due to financial losses.
An ESMO consensus on how to manage cancer patients during the pandemic was published last July 2020, 24  we recommend studies focusing on specific types of cancers and how they are affected by treatment delays. We also recommend further studies on treatment modifications or regimen changes. Longer follow-up can also be done to assess mortality and overall survival.

| CONCLUSION
In conclusion, our findings suggest that the risks of cancer progression due to treatment delays exceed the risks of Covid-19 infection in cancer patients, hence, implying that beneficial treatment should not be delayed as much as possible. This study also revealed a lack in adequate disaster preparedness that leaves cancer patients at high risk for treatment delay and poor outcomes. Oncologists, policy-makers, and patients all have roles in moving toward optimal cancer care during this crisis. Cancer care during the pandemic is constantly changing and it is important that oncologists proceed with evidence-based care.
Current evidence on the impact of continuing or delaying cancer treatment during Covid-19 times is still lacking in strength, and physicians should keep track of new studies and recommendation changes. Patients should also be assured that they can safely seek treatment, meaning that cancer treatment centers must take the necessary measures to protect the patients' safety by, at a minimum, having adequate supplies of personal protective equipment and sufficient access to rapid COVID testing. Lastly, the impact of logistic problems on treatment delays serves as a call for policy makers to develop interventions that will mitigate these logistic and financial barriers such as provision of transport services to increase accessibility to treatment centers, and allotment of adequate cancer treatment centers, which to ensure continuity of cancer care services during the pandemic.
Despite the limitations of our study, our findings should help clinicians and policymakers in making evidence-based decisions as we continue to ensure that our patients receive the best cancer care during this pandemic and future pandemics to come.