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Delivery of Cancer Care in Ontario, Canada, During the First Year of the COVID-19 Pandemic

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

Question  Did the delivery of services within a cancer system change during the first year of the COVID-19 pandemic?

Findings  This population-based cohort study conducted in Ontario, Canada, found a total of 4 476 693 cancer care services during the first year of the COVID-19 pandemic, compared with 5 644 105 services in the year prior, representing a reduction of 20.7% and suggesting a backlog of 1 167 412 cancer services during the first pandemic year. Limited change was observed in systemic treatments and emergency or urgent imaging examinations and surgical procedures, while major reductions were observed in cancer screening tests, biopsies, surgical treatments, and new consultations for systemic and radiation treatment.

Meaning  These findings provide evidence on the deficits in cancer care that occurred during the first year of the COVID-19 pandemic that are likely to inform continued delivery of care, recovery, and future pandemic planning.


Importance  The COVID-19 pandemic has impacted cancer systems worldwide. Quantifying the changes is critical to informing the delivery of care while the pandemic continues, as well as for system recovery and future pandemic planning.

Objective  To quantify change in the delivery of cancer services across the continuum of care during the COVID-19 pandemic.

Design, Setting, and Participants  This population-based cohort study assessed cancer screening, imaging, diagnostic, treatment, and psychosocial oncological care services delivered in pediatric and adult populations in Ontario, Canada (population 14.7 million), from April 1, 2019, to March 1, 2021. Data were analyzed from May 1 to July 31, 2021.

Exposures  COVID-19 pandemic.

Main Outcomes and Measures  Cancer service volumes from the first year of the COVID-19 pandemic, defined as April 1, 2020, to March 31, 2021, were compared with volumes during a prepandemic period of April 1, 2019, to March 31, 2020.

Results  During the first year of the pandemic, there were a total of 4 476 693 cancer care services, compared with 5 644 105 services in the year prior, a difference of 20.7% fewer services of cancer care, representing a potential backlog of 1 167 412 cancer services. While there were less pronounced changes in systemic treatments, emergency and urgent imaging examinations (eg, 1.9% more parenteral systemic treatments) and surgical procedures (eg, 65% more urgent surgical procedures), major reductions were observed for most services beginning in March 2020. Compared with the year prior, during the first pandemic year, cancer screenings were reduced by 42.4% (−1 016 181 screening tests), cancer treatment surgical procedures by 14.1% (−8020 procedures), and radiation treatment visits by 21.0% (−141 629 visits). Biopsies to confirm cancer decreased by up to 41.2% and surgical cancer resections by up to 27.8% during the first pandemic wave. New consultation volumes also decreased, such as for systemic treatment (−8.2%) and radiation treatment (−9.3%). The use of virtual cancer care increased for systemic treatment and radiation treatment and psychosocial oncological care visits, increasing from 0% to 20% of total new or follow-up visits prior to the pandemic up to 78% of total visits in the first pandemic year.

Conclusions and Relevance  In this population-based cohort study in Ontario, Canada, large reductions in cancer service volumes were observed. While most services recovered to prepandemic levels at the end of the first pandemic year, a substantial care deficit likely accrued. The anticipated downstream morbidity and mortality associated with this deficit underscore the urgent need to address the backlog and recover cancer care and warrant further study.

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Article Information

Accepted for Publication: February 14, 2022.

Published: April 25, 2022. doi:10.1001/jamanetworkopen.2022.8855

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Walker MJ et al. JAMA Network Open.

Corresponding Author: Linda Rabeneck, MD, MPH, Department of Medicine, University of Toronto, 500-525 University Ave, Toronto, ON M5G 2L3, Canada (linda.rabeneck@utoronto.ca).

Author Contributions: Dr Walker had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Walker, Habbous, Espino-Hernández, Wood, Chaudhry, Vahid, Gao, Gutierrez, Rey, Kupets, Singh, Irish, Rabeneck.

Acquisition, analysis, or interpretation of data: Walker, Wang, Mazuryk, Skinner, Meggetto, Ashu, Habbous, Nazeri Rad, Espino-Hernández, Wood, Chaudhry, Vahid, Gao, Gallo-Hershberg, Zanchetta, Langer, Zwicker, Rey, Tammemägi, Tinmouth, Chiarelli, Singh, Warde, Forbes, Dobranowski, Irish, Rabeneck.

Drafting of the manuscript: Walker, Wang, Skinner, Ashu, Nazeri Rad, Wood, Chaudhry, Vahid, Singh, Irish.

Critical revision of the manuscript for important intellectual content: Walker, Mazuryk, Meggetto, Habbous, Espino-Hernández, Gao, Gallo-Hershberg, Gutierrez, Zanchetta, Langer, Zwicker, Rey, Tammemägi, Tinmouth, Kupets, Chiarelli, Singh, Warde, Forbes, Dobranowski, Rabeneck.

Statistical analysis: Walker, Wang, Mazuryk, Skinner, Ashu, Habbous, Nazeri Rad, Espino-Hernández, Wood, Vahid, Gao, Zanchetta, Zwicker, Rey, Kupets, Singh.

Administrative, technical, or material support: Walker, Skinner, Meggetto, Espino-Hernández, Wood, Chaudhry, Vahid, Gallo-Hershberg, Gutierrez, Rey, Tammemägi, Singh, Warde, Dobranowski, Rabeneck.

Supervision: Nazeri Rad, Wood, Chaudhry, Rey, Tammemägi, Singh, Forbes, Dobranowski, Irish, Rabeneck.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was conducted with the support of Ontario Health–Cancer Care Ontario through in-kind contributions.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Cancer Care Ontario COVID-19 Impact Working Group: Members of the Cancer Care Ontario COVID-19 Impact Working Group are listed in Supplement 2.

Disclaimer: The opinions, results, view, and conclusions reported in this publication are those of the authors and do not necessarily reflect those of Ontario Health–Cancer Care Ontario. No endorsement by Ontario Health–Cancer Care Ontario is intended or should be inferred.

Additional Contributions: Katheryn Churchill, MSc, assisted with manuscript review; Jennifer Dekker, MSc, provided analytical support; Henry Hao, BSc, provided manuscript submission support; Yonda Lai, MN, assisted with literature review; Lynda MacNiven, BA, assisted with project planning; Victor Mak, MSc, provided analytical support; and Linh Tran, MHSc, MRT, assisted with manuscript review. They are affiliated with Ontario Health–Cancer Care Ontario and did not receive compensation outside their normal salaries.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

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It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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