Impact of the COVID-19 Pandemic on Treatment Patterns for Patients With Metastatic Solid Cancer in the United States

Ravi B. Parikh, MD, MPP; Samuel U. Takvorian, MD, MSHP; Daniel Vader, PhD; E. Paul Wileyto, PhD; Amy S. Clark, MD, MSCE; Daniel J. Lee, MD; Gaurav Goyal, MD; Gabrielle B. Rocque, MD, MSPH; Efrat Dotan, MD; Daniel M. Geynisman, MD; Pooja Phull, MD; Philippe E. Spiess, MD, MS, FRCS(C), FACS; Roger Y. Kim, MD; Amy J. Davidoff, PhD, MS; Cary P. Gross, MD; Natalia Neparidze, MD; Rebecca A. Miksad, MD, MPH; Gregory S. Calip, PharmD, MPH, PhD; Caleb M. Hearn, MPH; Will Ferrell, MPH; Lawrence N. Shulman, MD; Ronac Mamtani, MD, MSCE; Rebecca A. Hubbard, PhD


J Natl Cancer Inst. 2022;114(4):571-578. 

In This Article

Abstract and Introduction


Background: The COVID-19 pandemic has led to delays in patients seeking care for life-threatening conditions; however, its impact on treatment patterns for patients with metastatic cancer is unknown. We assessed the COVID-19 pandemic's impact on time to treatment initiation (TTI) and treatment selection for patients newly diagnosed with metastatic solid cancer.

Methods: We used an electronic health record–derived longitudinal database curated via technology-enabled abstraction to identify 14 136 US patients newly diagnosed with de novo or recurrent metastatic solid cancer between January 1 and July 31 in 2019 or 2020. Patients received care at approximately 280 predominantly community-based oncology practices. Controlled interrupted time series analyses assessed the impact of the COVID-19 pandemic period (April-July 2020) on TTI, defined as the number of days from metastatic diagnosis to receipt of first-line systemic therapy, and use of myelosuppressive therapy.

Results: The adjusted probability of treatment within 30 days of diagnosis was similar across periods (January-March 2019 = 41.7%, 95% confidence interval [CI] = 32.2% to 51.1%; April-July 2019 = 42.6%, 95% CI = 32.4% to 52.7%; January-March 2020 = 44.5%, 95% CI = 30.4% to 58.6%; April-July 2020 = 46.8%, 95% CI= 34.6% to 59.0%; adjusted percentage-point difference-in-differences = 1.4%, 95% CI = −2.7% to 5.5%). Among 5962 patients who received first-line systemic therapy, there was no association between the pandemic period and use of myelosuppressive therapy (adjusted percentage-point difference-in-differences = 1.6%, 95% CI = −2.6% to 5.8%). There was no meaningful effect modification by cancer type, race, or age.

Conclusions: Despite known pandemic-related delays in surveillance and diagnosis, the COVID-19 pandemic did not affect TTI or treatment selection for patients with metastatic solid cancers.


The COVID-19 pandemic has led to declines in patients seeking care for life-threatening conditions, such as acute myocardial infarction and stroke, as well as care delays for screening and management of chronic medical conditions.[1–5] For patients with cancer, who may be particularly vulnerable to COVID-19 infection,[6–8] early research suggested changes in practice patterns leading to care delays and treatment modifications.[9–17] Some of these changes were supported by guidelines issued during the pandemic,[18] which encouraged consideration of nonmyelosuppressive regimens despite mixed evidence linking the risk and severity of COVID-19 infection to immunosuppression from cancer therapy.[8,19–21] These care disruptions may have been particularly prominent for patients with metastatic cancer for whom treatments are palliative rather than curative. A recent systematic review identified 62 studies evaluating pandemic-related delays across the cancer care continuum; however, the majority of these studies used single-institution data and did not focus on patients with metastatic cancer.[22] Thus, little is known about the impact of the pandemic on changes in treatment patterns for patients with metastatic cancer.

Because treatment delays cause patient distress and are associated with increased mortality for patients with cancer,[23–27] time to treatment initiation (TTI) is a patient-centered quality metric and outcome that has been used to evaluate the impact of health policies on cancer care.[9,28,29] TTI may also serve as a barometer of capacity limitation and care delivery disruption during the COVID-19 pandemic.[30–34] Moreover, pandemic-related delays or changes in cancer treatment may have disproportionately affected minority groups, including African American patients, who even before the pandemic were less likely to receive guideline-concordant systemic therapy for metastatic cancer than White patients.[35–40] It is thus critical to identify whether the COVID-19 pandemic resulted in changes in treatment patterns for patients with metastatic cancer, with potential downstream consequences that could adversely affect patient outcomes and equitable cancer care.

The objective of this study was to evaluate the impact of the COVID-19 pandemic on TTI and treatment selection for patients newly diagnosed with metastatic solid cancer, with attention to race- and age-based disparities. We hypothesized that the pandemic would be associated with delays in initiation of systemic therapy and increased use of nonmyelosuppressive therapies.