Background The COVID-19 pandemic led to significant disruptions in cancer diagnosis and treatment in India. This retrospective study with two participating centres aimed to classify and quantify the delays and disruptions in cervical cancer care during the pandemic and evaluate their impact on treatment outcomes.

Methods Records of newly diagnosed patients of cervical cancer registered in between March 2020 and December 2021 were evaluated. A delay group was identified if there was either a gap of more than 3 months from onset of symptoms to histological proof or a gap of more than 6 weeks from diagnosis to start of treatment or a gap of more than 4 consecutive days during Radiotherapy (RT). The cause for the delays and its impact on stage and treatment were identified. Survival curves were plotted using the Kaplan Meir method and differences in survival were analysed using the log rank test.

Results Out of the 418 cervical cancer patients eligible for final analysis registered, 268 (64·1%) were found to have a delay. While a diagnostic delay was noted in 220 (52·6%) patients, a delay in start of treatment was seen in 126 (30·1%) and treatment interruption was seen in 84 (20%) patients. Logistic delays were the most common cause (54%) followed by delays due to COVID 19 infection (7·6%). The delay group had a higher proportion of patients with metastatic disease-Stage IVB (5·9% vs 0·6%) and a lower proportion of patients with early stage disease – Stage I-IIA (7·4 % vs 9·3%) compared to the group without delays(p=0·02). Upward Stage migration was seen in 22% of patients in the Delay group and 11·3% of patients in the No Delay group (p=0·004). Definitive Radiotherapy (RT) followed by Brachytherapy was the most common treatment modality (63·8% of cohort). The proportion of patients receiving external supplementary boost (12·6% vs 9·3%) and Palliative RT (4% vs 0·6%) was higher in the Delay group as compared to the No Delay group (p=<0·001). After a median follow up of 37 months, The 1 year, 2 year and 3 year Overall Survival (OS) was 75%, 58% and 52% in the Delay group and 92%, 87% and 84% in the group without delays respectively (p<0·001).The 1 year, 2 year and 3 year PFS was 65%, 54% and 46% in the Delay group and 91%, 86% and 79% in the group without delays respectively (p<0·001).

Conclusion Delays and disruptions in cervical cancer care during the COVID-19 pandemic led to tumour upstaging and worsened survival outcomes. This highlights the urgent need for developing strategies aimed at optimal resource utilisation and minimizing delays in the event of a future pandemic.

WHAT IS ALREADY KNOWN ON THIS TOPIC The COVID-19 pandemic severely disrupted cancer care, worsening delays in diagnosis and treatment, particularly in low- and middle-income countries like India. Cervical cancer patients faced increased risks due to interruptions in radiotherapy and diagnostic delays. It is well documented that prolongation of overall treatment time can adversely affect treatment outcomes in patients with cervical cancer .

WHAT THIS STUDY ADDS To our knowledge, this retrospective cohort study from two institutions is the first study that reports the real-world impact of the COVID 19 pandemic on cervical cancer survival outcomes in India. In this study we describe and stratify the various kinds of delay – namely diagnostic delay, delay in initiation of treatment and delay during treatment. We demonstrate increased incidence of upward stage migration in patients with delays. The overall survival and progression free survival was significantly worse in the group with delays as compared to the group without delays. We also show that most of the delays are attributable to logistic reasons rather than COVID 19 infection. Delays caused by COVID 19 did not significantly influence survival outcomes.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY The findings of this study seem to suggest that COVID 19 based nationwide lockdowns, inadvertently led to significant disruptions in cervical cancer care, resulting in poorer patient outcomes. This study highlights the urgent need for developing strategies aimed at optimal resource utilisation and minimizing delays in the event of a future pandemic.

The authors have declared no competing interest.

The first author has received a travel grant from Anusandhan National Research Foundation (ANRF) to present part of the results at ESMO ASIA 2024 in Singapore. No other funding has been received

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