In 2020 the world faced a new reality when it had to cope with the SARS-CoV-2 pandemic. Many aspects of people’s lives were affected by the illness itself and the measures taken to restrain viral spread. Healthcare services struggled to find a balance between treating the large numbers of covid-19 patients and continuing regular non-covid patientcare.
The number of examined pathology specimens is an indirect measure for a part of the healthcare provided. The changes in specimen numbers may help understand which areas of clinical care were affected most during the pandemic and are at risk to suffer long term effects. The Netherlands has a nationwide database containing all pathology reports since 1991 (PALGA), which creates an outstanding opportunity to study this impact and to explore which areas were affected most.
In line with the number of hospital admissions and number of persons dying from covid-19, the strongest decline in specimen numbers was observed during the first spike of the pandemic. The decrease in this period was very high (67%), but total numbers remained below expected during the whole year (overall decrease of 18%). A second dip during the second lockdown was seen for some tissue types and procedures, although much less prominent. Moreover, not all specimen types were affected equally.
During the first lockdown national screening programmes for colorectal carcinoma, breast carcinoma and cervical carcinoma were paused. This explains the huge decline in cytology specimens from cervix and breast (88% and 65% respectively) and the strong decrease in histological specimens from the lower gastrointestinal tract (65%) in period 1. Although screening was resumed after the first lockdown, cervical cytology numbers remained below expected levels throughout the year. Colorectal biopsies containing a malignancy returned to expected levels after period 1, but breast biopsies from malignant lesions were below expected in period 2 as well. Moreover, numbers of resected malignancies remained lower than expected for both lower gastrointestinal tract and breast in period 2 and 3 and period 2–4 respectively.
Part of these numbers were previously reported by the Dutch Cancer Registry (Integraal Kankercentrum Nederland, IKNL), which reported a drop in the numbers of stage I colorectal carcinoma, early stages of breast cancer and breast carcinoma in situ due to the temporarily suspended screening programmes. Numbers of newly diagnosed patients returned to expected levels in autumn  [https://iknl.nl/covid-19/covid-19-en-kanker-van-de-spijsverteringsorganen] [ https://iknl.nl/covid-19/covid-19-en-borstkanker]
The decline in resected malignancies from lower gastrointestinal tract, female genital tract and breast after period 1 might not only reflect a lower number of cancer diagnoses. It might be that a choice for other (neoadjuvant) treatment modalities like radiotherapy and/or chemotherapy was made more frequently under the given circumstances, thus postponing surgery and putting less strain on intensive care facilities . However, a catch-up in numbers is not seen.
In the normal situation histology of the skin makes up the largest part of the diagnostic volume in Dutch pathology laboratories, but during the first lockdown numbers plummeted with 72%. Although biopsies and resections from benign skin disease remained low, a slight catch-up (between 5–9%) was seen for malignant skin disease after period 1. Skin care might belong to the clinical areas which are delayed relatively easily in times of crisis because many skin diseases are not or may not seem immediately life-threatening. Moreover, patients might delay seeking care for lesions that do not cause severe symptoms [8, 9].
In contrast to the areas discussed above, other areas seem hardly affected by the pandemic. It is not surprising that placentas belong to this category, but remarkably numbers for pancreas, central nervous system (CNS) and liver remained relatively stable as well. Considering that diseases of these organs are often treated in specialised tertiary care centres, it raises the question whether their relatively stable numbers result from a conscious choice to prioritise the treatment of certain diseases, whether the stable numbers are caused by the severity of presenting symptoms or whether the way in which covid-19 patients were spread over the Dutch hospitals, dictated indirectly which non-covid patientcare could be continued.
Apart from the areas discussed above, a general observation is that the number of specimens containing a malignancy decreased relatively less than the number of specimens with benign disease, suggesting that a serious effort was made to continue cancer care as much as possible. This is supported by the fact that the number of resections for malignancies dropped less than the number of biopsies. The decline in biopsy numbers might, although partly attributed to the pause in screening programmes, also be due to people’s reluctancy to seek medical care. The observation that cytology numbers were affected less than biopsy numbers might be explained by the slightly different role of cytology in the diagnostic process.
Catch-up in numbers after the first lock down dip was minimal. It was only seen for histology and the maximum was 17% (for benign resections of the colon). In all other instances in which some catch up was observed (e.g. resections of malignant skin lesions) the catch-up was less than 10%.
Because the pandemic put a strain on intensive care availability, this indirectly affected surgical capacity. A Dutch research group developed a model to predict the health impact of postponing surgical procedures for both benign and malignant disease by estimating the disability-adjusted life-years per month of delay . This model shows that 20 of the 23 surgical procedures for which a delay would have the strongest negative impact, were oncological. Our analyses show that surgery for malignant disease was relatively spared during the corona crisis, which seems a logical choice based on the data from the Gravesteijn study.
The situation for benign disease is more difficult to assess. Most of the surgical procedures for benign disease included in the study by Gravesteijn et al. do not produce pathology specimens. So similar studies/models for different procedures are needed to assess the impact of the decrease in benign specimens observed in our study, as in the study of Te Groen et al . The procedures involved in the catch-up seen for benign resections of the lower GI-tract in our study might be the follow-up of their results.
Although the PALGA-database covers pathology reports nationwide and many areas of patientcare, it obviously does not include all healthcare areas. Because the results of this study reflect the Dutch situation, it might in several respects be different from the situation in other countries. Moreover, for some categories specimen numbers were too small for meaningful analysis. Despite these limitations the results of this study highlight remarkable changes in patientcare during the corona crisis. The impact is yet unknown, but it raises important questions:
What is the consequence of the pause in national screening programmes? Will the experiences of the past year, with a decline (and thus at least partly delay) in the number of surgical interventions, lead to a shift in the use of different treatment modalities for certain diseases (e.g. chemoradiotherapy instead of surgery)? Will there be a worse outcome for patient with postponed cancer diagnosis and/or treatment? What is the impact on health and quality of life of delaying surgery (skin, soft tissue, breast, gallbladder, prostate) or biopsy diagnosis (colon) for benign disease? Should a new or continuing pandemic lead to different healthcare choices?
Together with studies on the health impact of postponing surgical procedures , the data presented here help to assess the consequences of the corona pandemic on (public) health and provide a starting point in the discussion on how to make the best choices in times of scarce healthcare resources, recognizing the impact of both benign and malignant disease on quality of life.