Two-year follow up on the impact of the COVID-19 pandemic on outcomes in gynecologic oncology patients

Objectives: We previously showed that gynecologic oncology (GO) referrals decreased significantly during the COVID-19 pandemic. We aimed to evaluate the impact of the pandemic on survival outcomes for GO patients. Our secondary objective was to assess survival outcomes by insurance status as a proxy for access to care. Methods: We conducted a retrospective cohort study of 386 patients referred for GO evaluation at an NCI-designated cancer center from Sept 2019 to mid-Mar 2020 (pre-COVID), and mid-Mar to Aug 2020 (COVID). Progression-free (PFS) and overall survival (OS) were compared between the 2 periods from 3 time points (date referral was placed, initial GO evaluation, and start of GO therapy) to date of last follow-up or death. 2-year survival outcomes were stratified by insurance status. Models were adjusted for age, insurance status, stage, and disease site. Results: Among 386 referred patients with a confirmed gynecologic cancer, 49% had private insurance, 38.1% had Medicare, and 12.7% had no/Medicaid insurance. 57% had uterine cancer followed by ovarian/fallopian tube/primary peritoneal (22.3%) and cervical cancers (20.9%). Characteristics were similar pre-COVID vs COVID aside from age [median 63.1 (pre-COVID) vs 58.6 (COVID), p=0.01]. PFS from time of referral was lower among patients referred during COVID [adjusted HR (aHR) 1.54, 95% CI 1.01–2.33]. PFS from time of initial evaluation (aHR 1.54, 95% CI 1.02–2.34) and start of therapy (aHR 1.53, 95% CI 1.01–2.33) was lower among patients referred during the pandemic. OS from time of referral (aHR 1.97, 95% CI 1.10–3.53) and initial evaluation (aHR 1.79, 95% CI 1.02–3.17) was worse for patients referred during COVID. OS from start of therapy was similar. Compared to patients with private insurance, those with Medicare had a higher hazard of progression and death at all time points, but these differences dissipated after adjustment. [Formula presented] Conclusions: Patients referred to GO at our institution during the early months of COVID-19 experienced worse 2-year PFS and OS compared to patients referred before the pandemic. Once treatment began, OS was similar. Insurance status was not associated with survival after adjustment, suggesting the strain of COVID on healthcare systems and individuals drives disparities in outcomes two years later. Future studies are needed to fully realize the impact of COVID on GO outcomes.