Research Letter | Oncology

Comparison of Early- and Late-Stage Breast and Colorectal Cancer Diagnoses

During vs Before the COVID-19 Pandemic
Jade Zifei Zhou, MD, PhD; Shelly Kane, MPH; Celia Ramsey, BS; Melody Akhondzadeh, MSN, RN; Ananya Banerjee, MPH; Rebecca Shatsky, MD; Kathryn Ann Gold, MD

Introduction Author affiliations and article information are

listed at the end of this article.
Breast and colorectal cancers are often detected through routine screening of asymptomatic
individuals. Effective cancer screening has led to improvements in survival as a result of increased
detection of earlier-stage cancer, while decreasing the incidence of late-stage cancer diagnoses.1,2
The ongoing COVID-19 pandemic has posed a substantial challenge in cancer care by disrupting
cancer screening procedures such as mammograms and colonoscopies.3 We sought to compare the
incidence of early- and late-stage breast and colorectal cancer diagnoses during vs before the
COVID-19 pandemic among patients at our institution.

Methods
This quality improvement study was approved by the University of California San Diego Aligning and
Coordinating Quality Improvement, Research and Evaluation (ACQUIRE) Committee and was
deemed exempt from institutional review board approval. Informed consent was waived as per
recommendations from the ACQUIRE Committee. The study followed the Standards for Quality
Improvement Reporting Excellence (SQUIRE) reporting guideline.
We examined cancer staging for all patients at their first presentation to Moores Cancer Center
at University of California San Diego Health for a new diagnosis of malignant neoplasm or a second
opinion in 2019 and 2020. To determine the stage at presentation for all patients, the treating
clinicians used the American Joint Committee on Cancer staging module (8th edition) in the
electronic medical record.4 We compared the stage distribution at presentation in 2019 vs 2020 for
cancers overall and for colorectal and breast cancers. The Fisher exact test was used to compare the
proportions of stage I or stage IV breast cancer, colorectal cancer, and all cancers between 2019 and
2020. Odds ratios (ORs) with 95% CIs and P values are reported. The threshold for statistical
significance was set at P < .05. Statistical analysis was performed with R software (version 3.6.3; R
Project for Statistical Computing).

Results
The study included 55 men (10.5%) and women 467 (89.5%) with a mean (SD) age of 58.1 (13.5)
years. Demographic characteristics of the study participants are shown in the Table. Race and
ethnicity data were obtained by self-report as part of the standard of care in our electronic medical
record. The total number of new patient visits for malignant neoplasm was similar in 2019 vs 2020
(1894 vs 1915). In addition, the overall stage distribution for all patients with cancer was similar, with
605 patients (31.9%) with stage I disease in 2019 vs 556 (29.0%) in 2020 (OR, 1.15 [95% CI,
1.00-1.32]; P = .05) and 492 patients (26.0%) with stage IV disease in 2019 vs 506 (26.4%) in 2020
(OR, 0.98 [95% CI, 0.84-1.13]; P = .77).
After the start of the COVID-19 pandemic, we saw a numeric but no statistically significant
change in the number of patients presenting with stage I colorectal cancer in 2019 vs 2020 (8
[17.8%] vs 6 [14.6%], respectively; OR, 1.26 [95% CI, 0.34-4.88], P = .78); the same was true for

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 JAMA Network Open | Oncology Breast and Colorectal Cancer Diagnosis Stage During vs Before the COVID-19 Pandemic

patients presenting with stage IV disease (3 [6.7%] vs 8 [19.5%], respectively; OR, 0.3 [95% CI, 0.05-
1.37], P = .11). Among patients with breast cancer, we saw a significantly lower percentage of patients
presenting with stage I disease in 2019 vs 2020 after the start of the COVID-19 pandemic (138
[63.9%] vs 116 [51.3%], respectively; OR, 1.67 [95% CI, 1.13-2.47]; P = .008) and a significantly higher
number of patients presenting with stage IV breast cancer (4 [1.9%] vs 14 [6.2%], respectively; OR,
0.33 [95% CI, 0.09-0.98]; P = .04) (Figure). Recent data for January through March 2021
demonstrate a continuing trend of a lower percentage of patients with breast cancer presenting with
stage I disease (26 [41.9%]) and an increased percentage of stage IV disease (5 [8.0%]).

Discussion
The COVID-19 pandemic has profoundly influenced how we deliver cancer care. The results of this
quality improvement study suggest that the incidence of late-stage presentation of colorectal and
breast cancers at our institution has increased since the start of the pandemic in 2020,
corresponding with a decrease in the early-stage presentation of these cancers.
There are several limitations to our study. First, this was a single-center study, and we were
unable to assess causality. Second, our numbers of patients with colorectal cancer were relatively
small. Finally, our analysis included patients seeking a second opinion, which included individuals
with treatment-naive as well as treatment-refractory disease.

Table. Patient Characteristics in 2019 vs 2020

2019, No. (%) 2020, No. (%)

Breast cancer Colorectal cancer Breast cancer Colorectal cancer
Characteristic (n = 216) (n = 45) (n = 220) (n = 41)
Biological sex
Men 1 (0.5) 24 (53.3) 2 (0.9) 28 (68.3)
Women 215 (99.5) 21 (46.7) 218 (99.1) 13 (31.7)
Racea
Asian and Pacific Islander 29 (13.4) 6 (13.3) 23 (10.5) 2 (4.9)
Black 3 (1.4) 1 (2.2) 8 (3.6) 3 (7.3)
White 102 (47.2) 26 (57.8) 120 (54.6) 17 (41.5)
a
Unreportedb 82 (38.0) 12 (26.7) 69 (31.4) 19 (46.3) Values total 100% each for the race and ethnicity
categories, as these data were gathered separately.
Ethnicity
b
Hispanic 59 (27.3) 14 (31.1) 57 (25.9) 13 (31.7) All patients were given the option of whether to
specify their race, and this group of patients opted
Non-Hispanic 157 (72.7) 31 (68.9) 163 (74.1) 28 (68.3)
not to report their racial background.

Figure. Stage Distribution of Patients With Breast Cancer Presenting for Their Initial Visit in 2019 Compared
With 2020 and January to March 2021

80
2019
2020

60 2021
Patients, %

40

20

0
Stage I Stage IV
Breast cancer stage at diagnosis

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 JAMA Network Open | Oncology Breast and Colorectal Cancer Diagnosis Stage During vs Before the COVID-19 Pandemic

Cancer screening is integral to cancer prevention and control, particularly in colorectal and
breast cancers. There is increasing concern regarding the effect of the COVID-19 pandemic on cancer
mortality, as the evidence suggests that the number of patients presenting at late, incurable stages
is increasing. Patients who have delayed preventative care during the pandemic should be
encouraged to resume treatment as soon as possible.

ARTICLE INFORMATION
Accepted for Publication: December 23, 2021.
Published: February 15, 2022. doi:10.1001/jamanetworkopen.2021.48581
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Zhou JZ
et al. JAMA Network Open.
Corresponding Author: Jade Zifei Zhou, MD, PhD, Moores Cancer Center at University of California San Diego
Health, 3855 Health Sciences Dr, MC 0829, La Jolla, CA 92093-0829 (jzzhou@health.ucsd.edu).
Author Affiliations: Moores Cancer Center at University of California San Diego Health, La Jolla, California.
Author Contributions: Drs Gold and Zhou had full access to all the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Gold.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Zhou, Ramsey, Gold.
Critical revision of the manuscript for important intellectual content: Zhou, Kane, Akhondzadeh, Banerjee,
Shatsky, Gold.
Statistical analysis: Shatsky, Gold.
Administrative, technical, or material support: Kane, Ramsey, Akhondzadeh, Gold.
Supervision: Shatsky, Gold.
Conflict of Interest Disclosures: Dr Gold reported receiving personal fees from AstraZeneca; personal fees from
Takeda, Rakuten, and Regeneron; and grants from Pfizer and Pharmacyclics outside the submitted work. No other
disclosures were reported.
Additional Contributions: We thank Jing Zhang, MSc (Moores Cancer Center, University of California San Diego
Health), for assistance with statistical analysis. There was no financial compensation for this contribution.

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