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Gastrointestinal Cancer Stage at Diagnosis Before and During the COVID-19 Pandemic in Japan

Educational Objective
To identify the key insights or developments described in this article
Key Points

Question  Is the COVID-19 pandemic associated with the stage at which gastrointestinal cancer is diagnosed in Japan?

Findings  In this cohort study of 5167 patients, significant decreases were observed for the diagnosis of stage I gastric cancer and stage 0 to II colorectal cancer, whereas a significant increase was observed for the diagnosis of stage III colorectal cancer.

Meaning  These findings suggest that during the COVID-19 pandemic, there may have been fewer cases of screening-detected gastrointestinal cancer, and colorectal cancer may have been diagnosed at more advanced stages.


Importance  The COVID-19 pandemic has delayed medical consultations, possibly leading to the diagnosis of gastrointestinal cancer at advanced stages.

Objective  To evaluate stage at diagnosis among patients with gastrointestinal cancer in Japan before and during the COVID-19 pandemic.

Design, Setting, and Participants  This retrospective cohort study included patients in a hospital-based cancer registry who were diagnosed with gastrointestinal cancer (ie, esophageal, gastric, colorectal, pancreatic, liver, and biliary tract cancers) between January 2016 and December 2020 at 2 tertiary Japanese hospitals.

Exposures  The pre–COVID-19 period was defined as January 2017 to February 2020, and the COVID-19 period was defined as March 2020 to December 2020.

Main Outcome and Measure  Monthly numbers of patients with newly diagnosed cancer were aggregated, classified by stage, and compared.

Results  The study evaluated 5167 patients, including 4218 patients (2825 [67.0%] men; mean [SD] age, 71.3 [10.9] years) in the pre–COVID-19 period and 949 patients (607 [64.0%] men; mean [SD] age, 71.8 [10.7] years) in the COVID-19 period. Comparing the pre–COVID-19 period with the COVID-19 period, significant decreases were observed in the mean (SD) number of patients with newly diagnosed gastric cancer (30.63 [6.62] patients/month vs 22.40 [5.85] patients/month; –26.87% change; P < .001) and colorectal cancer (41.61 [6.81] patients/month vs 36.00 [6.72] patients/month; –13.47% change; P = .03). Significant decreases were also observed in the mean (SD) number of cases of stage I gastric cancer (21.55 [5.66] cases/month vs 13.90 [5.99] cases/month; –35.51% change; P < .001), stage 0 colorectal cancer (10.58 [3.36] cases/month vs 7.10 [4.10] cases/month; –32.89% change; P = .008), and stage I colorectal cancer (10.16 [3.14] cases/month vs 6.70 [2.91] cases/month; –34.04% change; P = .003). No significant increases were observed for esophageal, gastric, pancreatic, liver, or biliary tract cancers. A significant decrease was observed in the mean (SD) number of cases per month of stage II colorectal cancer (7.42 [3.06] cases/month vs 4.80 [1.75] cases/month; –35.32% change; P = .01); a significant increase was observed for the mean (SD) number of cases per month of stage III colorectal cancer (7.18 [2.85] cases/month vs 12.10 [2.42] cases/month; 68.42% change; P < .001).

Conclusions and Relevance  In this cohort study of patients in a hospital-based cancer registry form Japan, significantly fewer patients were diagnosed with stage I gastric and colorectal cancers during the COVID-19 pandemic. Thus, the number of screening-detected cancers might have decreased, and colorectal cancer may have been diagnosed at more advanced stages.

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Article Information

Accepted for Publication: July 26, 2021.

Published: September 21, 2021. doi:10.1001/jamanetworkopen.2021.26334

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kuzuu K et al. JAMA Network Open.

Corresponding Author: Takuma Higurashi, MD, PhD, Department of Gastroenterology and Hepatology, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan (

Author Contributions: Drs Higurashi and Nakajima had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors reviewed the final version of the manuscript and agreed to its submission.

Concept and design: Kuzuu, Misawa, Ashikari, Hosono, Matsushima, Komatsu, Nakajima, Higurashi.

Acquisition, analysis, or interpretation of data: Kuzuu, Misawa, Kessoku, Kato, Yoneda, Nonaka.

Drafting of the manuscript: Kuzuu, Misawa, Ashikari, Hosono, Komatsu.

Critical revision of the manuscript for important intellectual content: Kuzuu, Misawa, Kessoku, Kato, Yoneda, Nonaka, Matsushima, Nakajima, Higurashi.

Statistical analysis: Kuzuu, Misawa.

Obtained funding: Nonaka.

Administrative, technical, or material support: Misawa, Kessoku, Kato, Komatsu, Nakajima, Higurashi.

Supervision: Ashikari, Kessoku, Hosono, Yoneda, Matsushima, Nakajima, Higurashi.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the staff at each participating institution for their support with data collection.

Oran  DP , Topol  EJ .  The proportion of SARS-CoV-2 infections that are asymptomatic: a systematic review.   Ann Intern Med. 2021;174(5):655-662. doi:10.7326/M20-6976PubMedGoogle ScholarCrossref
Miyake  S , Ashikari  K , Kato  S ,  et al.  Severe acute respiratory syndrome coronavirus 2 prevalence in saliva and gastric and intestinal fluid in patients undergoing gastrointestinal endoscopy in coronavirus disease 2019 endemic areas: prospective cross-sectional study in Japan.   Dig Endosc. Published online February 6, 2021. doi:10.1111/den.13945PubMedGoogle Scholar
European Centre for Disease Prevention and Control. Transmission of COVID-19. Accessed March 28, 2021.
US Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Accessed March 28, 2021.
Brauner  JM , Mindermann  S , Sharma  M ,  et al.  Inferring the effectiveness of government interventions against COVID-19.   Science. 2021;371(6531):eabd9338. doi:10.1126/science.abd9338PubMedGoogle Scholar
Alfano  V , Ercolano  S .  The efficacy of lockdown against COVID-19: a cross-country panel analysis.   Appl Health Econ Health Policy. 2020;18(4):509-517. doi:10.1007/s40258-020-00596-3PubMedGoogle ScholarCrossref
Siegler  JE , Heslin  ME , Thau  L , Smith  A , Jovin  TG .  Falling stroke rates during COVID-19 pandemic at a comprehensive stroke center.   J Stroke Cerebrovasc Dis. 2020;29(8):104953. doi:10.1016/j.jstrokecerebrovasdis.2020.104953PubMedGoogle Scholar
Colivicchi  F , Di Fusco  SA , Magnanti  M , Cipriani  M , Imperoli  G .  The impact of the coronavirus disease-2019 pandemic and Italian lockdown measures on clinical presentation and management of acute heart failure.   J Card Fail. 2020;26(6):464-465. doi:10.1016/j.cardfail.2020.05.007PubMedGoogle ScholarCrossref
Nopp  S , Janata-Schwatczek  K , Prosch  H ,  et al.  Pulmonary embolism during the COVID-19 pandemic: decline in diagnostic procedures and incidence at a university hospital.   Res Pract Thromb Haemost. 2020;4(5):835-841. doi:10.1002/rth2.12391PubMedGoogle ScholarCrossref
Kaufman  HW , Chen  Z , Niles  J , Fesko  Y .  Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (COVID-19) pandemic.   JAMA Netw Open. 2020;3(8):e2017267. doi:10.1001/jamanetworkopen.2020.17267PubMedGoogle Scholar
Rutter  MD , Brookes  M , Lee  TJ , Rogers  P , Sharp  L .  Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.   Gut. 2021;70(3):537-543. doi:10.1136/gutjnl-2020-322179PubMedGoogle ScholarCrossref
De Vincentiis  L , Carr  RA , Mariani  MP , Ferrara  G .  Cancer diagnostic rates during the 2020 ‘lockdown’, due to COVID-19 pandemic, compared with the 2018-2019: an audit study from cellular pathology.   J Clin Pathol. 2021;74(3):187-189. doi:10.1136/jclinpath-2020-206833PubMedGoogle ScholarCrossref
Dinmohamed  AG , Visser  O , Verhoeven  RHA ,  et al.  Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands.   Lancet Oncol. 2020;21(6):750-751. doi:10.1016/S1470-2045(20)30265-5PubMedGoogle ScholarCrossref
Earnshaw  CH , Hunter  HJA , McMullen  E , Griffiths  CEM , Warren  RB .  Reduction in skin cancer diagnosis, and overall cancer referrals, during the COVID-19 pandemic.   Br J Dermatol. 2020;183(4):792-794. doi:10.1111/bjd.19267PubMedGoogle ScholarCrossref
Jacob  L , Loosen  SH , Kalder  M , Luedde  T , Roderburg  C , Kostev  K .  Impact of the COVID-19 pandemic on cancer diagnoses in general and specialized practices in Germany.   Cancers (Basel). 2021;13(3):408. doi:10.3390/cancers13030408PubMedGoogle ScholarCrossref
Zadnik  V , Mihor  A , Tomsic  S ,  et al.  Impact of COVID-19 on cancer diagnosis and management in Slovenia—preliminary results.   Radiol Oncol. 2020;54(3):329-334. doi:10.2478/raon-2020-0048PubMedGoogle ScholarCrossref
Mahase  E .  COVID-19: urgent cancer referrals fall by 60%, showing “brutal” impact of pandemic.   BMJ. 2020;369:m2386. doi:10.1136/bmj.m2386PubMedGoogle Scholar
Lai  A , Pasea  L , Banerjee  A ,  et al.  Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency.   medRxiv. Preprint published online June 1, 2020. doi:10.13140/RG.2.2.34254.82242Google Scholar
Maringe  C , Spicer  J , Morris  M ,  et al.  The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study.   Lancet Oncol. 2020;21(8):1023-1034. doi:10.1016/S1470-2045(20)30388-0PubMedGoogle ScholarCrossref
Miyake  S , Higurashi  T , Jono  T ,  et al.  Real-world evaluation of a computed tomography-first triage strategy for suspected Coronavirus disease 2019 in outpatients in Japan: an observational cohort study.   Medicine (Baltimore). 2021;100(22):e26161. doi:10.1097/MD.0000000000026161PubMedGoogle Scholar
Cancer Information Service, National Cancer Center, Japan (Ministry of Health, Labour and Welfare, National Cancer Registry). Cancer statistics. Accessed March 28, 2021.
Ruhl  JL , Callaghan  C , Hurlbut  A, , Ries  LAG , Adamo  P , Dickie  L , Schussler  N , eds.  Summary Stage 2018: Codes and Coding Instructions, National Cancer Institute; 2020.
Sun  S , Klebaner  F , Tian  T .  A new model of time scheme for progression of colorectal cancer.   BMC Syst Biol. 2014;8(suppl 3):S2. doi:10.1186/1752-0509-8-S3-S2PubMedGoogle ScholarCrossref
Tada  M , Misaki  F , Kawai  K .  Growth rates of colorectal carcinoma and adenoma by roentgenologic follow-up observations.   Gastroenterol Jpn. 1984;19(6):550-555. doi:10.1007/BF02793869PubMedGoogle ScholarCrossref
Grass  F , Behm  KT , Duchalais  E ,  et al.  Impact of delay to surgery on survival in stage I-III colon cancer.   Eur J Surg Oncol. 2020;46(3):455-461. doi:10.1016/j.ejso.2019.11.513PubMedGoogle ScholarCrossref
Fligor  SC , Wang  S , Allar  BG ,  et al.  Gastrointestinal malignancies and the COVID-19 pandemic: evidence-based triage to surgery.   J Gastrointest Surg. 2020;24(10):2357-2373. doi:10.1007/s11605-020-04712-5PubMedGoogle ScholarCrossref
Johnson  BA , Waddimba  AC , Ogola  GO , Fleshman  JW  Jr , Preskitt  JT .  A systematic review and meta-analysis of surgery delays and survival in breast, lung and colon cancers: implication for surgical triage during the COVID-19 pandemic.   Am J Surg. 2020;222(2):311-318. doi:10.1016/j.amjsurg.2020.12.015PubMedGoogle ScholarCrossref
Sharma  C , Eltawil  KM , Renfrew  PD , Walsh  MJ , Molinari  M .  Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010.   World J Gastroenterol. 2011;17(7):867-897. doi:10.3748/wjg.v17.i7.867PubMedGoogle ScholarCrossref
Chakraborty  S , Baine  MJ , Sasson  AR , Batra  SK .  Current status of molecular markers for early detection of sporadic pancreatic cancer.   Biochim Biophys Acta. 2011;1815(1):44-64. doi:10.1016/j.bbcan.2010.09.002PubMedGoogle Scholar
Furukawa  H , Iwata  R , Moriyama  N .  Growth rate of pancreatic adenocarcinoma: initial clinical experience.   Pancreas. 2001;22(4):366-369. doi:10.1097/00006676-200105000-00005PubMedGoogle ScholarCrossref
Zhang  BH , Yang  BH , Tang  ZY .  Randomized controlled trial of screening for hepatocellular carcinoma.   J Cancer Res Clin Oncol. 2004;130(7):417-422. doi:10.1007/s00432-004-0552-0PubMedGoogle ScholarCrossref
Trinchet  JC , Chaffaut  C , Bourcier  V ,  et al; Groupe d’Etude et de Traitement du Carcinome Hépatocellulaire (GRETCH).  Ultrasonographic surveillance of hepatocellular carcinoma in cirrhosis: a randomized trial comparing 3- and 6-month periodicities.   Hepatology. 2011;54(6):1987-1997. doi:10.1002/hep.24545PubMedGoogle ScholarCrossref
Han  KH , Kim  DY , Park  JY ,  et al.  Survival of hepatocellular carcinoma patients may be improved in surveillance interval not more than 6 months compared with more than 6 months: a 15-year prospective study.   J Clin Gastroenterol. 2013;47(6):538-544. doi:10.1097/MCG.0b013e3182755c13PubMedGoogle ScholarCrossref
Aljiffry  M , Abdulelah  A , Walsh  M , Peltekian  K , Alwayn  I , Molinari  M .  Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature.   J Am Coll Surg. 2009;208(1):134-147. doi:10.1016/j.jamcollsurg.2008.09.007PubMedGoogle ScholarCrossref
Misra  S , Chaturvedi  A , Misra  NC , Sharma  ID .  Carcinoma of the gallbladder.   Lancet Oncol. 2003;4(3):167-176. doi:10.1016/S1470-2045(03)01021-0PubMedGoogle ScholarCrossref
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