The COVID-19 pandemic affected cancer care worldwide, including kidney cancer (KC) management, with studies reporting delays in both diagnosis and treatment [1–4]. These delays have been linked to changes in stage at diagnosis, prolonged waiting times, and poorer cancer-specific survival [1–3, 5, 6]. In Hungary, lockdown measures and the prioritization of COVID-19 patients similarly disrupted cancer services [7, 8].

Kidney cancer ranks as the third most common urological malignancy worldwide and renal cell carcinoma (RCC), which accounts for approximately 90% of kidney tumors, represents the main histological subtype [9]. KC shows marked gender differences, ranking as the fourteenth most frequent cancer in women and the ninth in men [9–11].The disease is often detected incidentally, with up to 85% of localized renal masses discovered during imaging for unrelated conditions [12]. Less than a third of RCC cases present with clinical symptoms, as small tumors are often asymptomatic [13]. Mortality from KC has paradoxically increased in certain European countries despite improvements in the disease’s management in recent decades [14]. Timely diagnosis is crucial, as prognosis depends on stage at presentation, with overall survival declining from 90% for localized disease to around 12% for patients with distant metastases [11, 15–17].

Delays in establishing a kidney cancer diagnosis and ultimately treatment arise from both patient- and healthcare-related factors. Patients may be asymptomatic or may overlook symptoms, contributing to patient-related delays [18]. Additional barriers may stem from healthcare-related delays — for example, limited diagnostic capacity, workforce shortages, long waiting lists for imaging or specialist services, and under-resourced hospitals- which ultimately influence clinical outcome [17, 19].

As a result of the pandemic both patients’ healthcare-seeking behavior and the organization of cancer care were affected [5, 20, 21]. Many people postponed cancer screening tests and delayed routine medical appointments due to fear of infection and limited access to services [21, 22]. During the pandemic, studies reported increased surgical wait times and higher rates of advanced or metastatic RCC. Janes et al. reported an increase in surgical wait times from 44.5 days pre-pandemic to 56.8 days during the pandemic (p = 0.003) [6]. A study in India reported a mean surgical delay of approximately 15 days for RCC patients attributed to COVID-19-related procedural changes, which prolonged overall treatment duration and increased costs [1]. A significant increase in metastatic RCC cases (13.1% vs. 6.1%, p = 0.01) and longer waiting times between imaging and surgery (35 vs. 30 days, p = 0.01) was reported in Turkey during this period [23].

There is limited data from the Central and Eastern European region on the effect of the pandemic on kidney cancer waiting times and the possible influencing factors of waiting times compared to Western countries [8]. In a recent study we reported changes in kidney cancer detection patterns and clinical characteristics during the pandemic [8], however to our knowledge, no studies have examined waiting times in this region.

Therefore, the aim of our study was to assess and compare the waiting times to initial diagnostic testing, initiation of treatment, and histopathological diagnosis as well as length of hospital stay among individuals diagnosed with KC during the pre-pandemic and pandemic periods. Furthermore, we aimed to identify potential predictors of prolonged waiting times across the two study intervals.

This study is among the few from the region to investigate kidney cancer waiting times and analyze the impact of the COVID-19 pandemic. We found that while median time to initial diagnostic testing (TDI) among symptomatic patients increased during the pandemic, time to treatment (TTI) and time to histopathological diagnosis (THI) remained stable. Advanced-stage disease was identified as a protective predictor against prolonged TDI in the pre-pandemic period and against prolonged THI during the pandemic.

Delays in care can be categorized as patient-related or healthcare-related. Patient-related delays—i.e., the interval until consulting a physician—often stem from personal decision-making barriers, or limited healthcare accessibility (e.g., appointment availability and diagnostic capacity) [24]. These factors make them a major contributor to overall diagnostic delay [24]. Survey data from an NCI-designated cancer center showed that during the COVID-19 pandemic delays in cancer-related care and preventive screening were common, particularly among patients with limited health literacy [21]. Furthermore, many patients postponed routine medical visits and cancer screening due to fear of infection and pandemic-related restrictions [20]. Our finding that TDI among symptomatic patients increased by 26 days during the pandemic suggests that similar phenomena may have taken place in the studied cohort.

The pandemic led to a sharp reduction in routine health checks and imaging, resulting in fewer incidentally detected small renal masses and a relative rise in symptomatic and advanced-stage presentations [2, 23]. Across Europe, North America, and Asia, this “stage migration” was consistently observed [1, 2]. More RCC patients presented with T3 or metastatic disease and symptomatic manifestations such as hematuria, rather than incidental findings [1, 2, 23]. The pandemic also substantially prolonged waiting times globally: a Canadian study found mean surgical delays increasing from 44.5 to 56.8 days (p = 0.003) during the pandemic [6], while Keskin et al. (2025) in Turkey reported fewer RCC surgeries, longer imaging-to-operation times (30–35 days; p = 0.01), larger tumors, and more metastatic cases in this period [25]. In India, a mean surgical delay of 15.19 days was reported and attributed to preoperative COVID-19 testing and related measures [1]. An investigation in Turkey also showed metastatic RCC rates nearly doubling (13.1% vs. 6.1%; p = 0.01) and longer imaging-to-operation times (35 vs. 30 days; p = 0.01) [23]. However, some reports have found no significant changes in time to treatment. According to a study in the Netherlands, median time from radiological diagnosis to surgical treatment was on average 48 days prior to the pandemic, and 46 days during the first wave of the pandemic [26]. Consistent with these findings, median TTI and THI did not change significantly in our cohort either. This suggests that the primary pandemic impact occurred before healthcare entry, as reflected by prolonged TDI. Once patients accessed the system, care pathways were largely maintained. It should be noted, however, that approximately 10% fewer KC cases were observed during the pandemic, primarily due to reduced incidental diagnoses, which may have decreased system burden and allowed routine cases to proceed without delay [8].

Median THI and TTI values (ranging between 95.5 and 111 days) in our study were longer than internationally reported values [3, 23, 26]. In Canada, a multicenter cohort study reported a median time from initial consultation to nephrectomy of 41 days, with stage-specific variation ranging from approximately 30–57 days depending on tumor stage [27]. Substantially shorter surgical pathways were demonstrated in a study in China, where median time from diagnosis to surgery was 16 days [28]. In cohorts from European and neighboring countries, median waiting times have been reported to be slightly longer, ranging between 30 and 48 days [23, 26].

Several factors may underlie the longer waiting times observed in our study. Although Hungarian law mandates CT or MRI within 14 days of cancer suspicion, scan interpretation can take an additional 4–10 days due to radiology staffing shortages [29]. Limited oncology specialists and surgical capacity outside major centers may also contribute to delays [29]. The Healthy Budapest Program for example reduced imaging waiting times, but intervals from diagnosis to therapy remained prolonged, likely due to referral processing, tumor board scheduling, preoperative evaluations, and operating room coordination [30]. These bottlenecks can cumulatively extend the time from diagnosis to surgery, reflecting systemic access challenges in Hungary [30]. Improving KC pathways would be particularly important, since waiting times exceeding 3 months have been associated with worse outcomes in RCC [17, 19]. In patients with T1b–T2a disease, delayed surgery exceeding approximately 90 days has been associated with decreased cancer-specific survival (HR 1.28; 95% CI 1.03–1.66) [19]. Similarly, in pT3 disease, nephrectomy delays longer than 10 weeks from diagnosis have been associated with worse overall survival (adjusted HR 1.13; 95% CI 1.04–1.24) [17]. These findings suggest that prolonged preoperative waiting times – as observed in our study- may be associated with adverse oncologic outcomes, particularly in advanced-stage disease.

Few studies have examined the pandemic’s effects on hospital length of hospital stay in KC patients. A recent Indian study reported a 15-day longer mean hospitalization during COVID-19, attributed to clearance protocols such as preoperative testing, chest CTs, and increased complication rates [1], while others linked longer stays to more advanced disease [23, 31]. In contrast, we found no significant difference in median LOH between the study periods. This could reflect offsetting factors: several studies document shortened hospital stays (up to 26%) during the pandemic due to strategies minimizing infection risk and preserving bed capacity, including expedited discharges and telemonitoring [32, 33]. It is plausible that hospital policy adaptations may have counterbalanced potential COVID-related delays in our setting.

Patient and tumor characteristics have been increasingly recognized as influential factors in the waiting times for diagnosis and treatment of patients with KC, particularly during the COVID-19 pandemic when healthcare resources were redirected [3, 5, 6, 23]. Previous studies have demonstrated that patients with advanced (T3 or T4) tumors experience markedly shorter waiting times compared to those with lower-stage disease [27, 34]. A recent systematic review reported that tumor aggressiveness and severity consistently drive accelerated care, whereas localized or asymptomatic cancers often experience longer diagnostic and waiting intervals [5].

In line with this, we found that advanced-stage disease was a protective factor against prolonged TDI, however only in the pre-pandemic period but not during the pandemic. This appears to be corroborated by international reports suggesting that between 20% and 31.4% of individuals avoided healthcare during the pandemic due to infection fear, even for potentially urgent symptoms [1, 5, 24, 35]. The phenomenon indicates the need for patient education, to recognize kidney cancer symptoms and seek timely care irrespective of external healthcare disruptions.

Advanced-stage disease was also a protective predictor against prolonged THI, but only during the pandemic. This aligns with findings that healthcare systems triage and prioritize care based on clinical urgency and likely reflects prioritization policies adapted to pandemic-related resource limitations [6, 23, 31]. In our cohort, this translated into the preferential fast-tracking of patients with advanced disease—likely associated with more overt symptoms or aggressive features—for urgent surgical intervention, thereby bypassing bottlenecks affecting earlier-stage cases. In contrast, asymptomatic patients with localized masses were more likely to experience “non-urgent” deferrals [8]. This pattern of care is in line with the European Association of Urology guidance, which put emphasis on the prioritization of symptomatic and high-stage renal tumors to avoid clinically meaningful delays [36].

Since THI was not influenced by the stage of cancer before the pandemic, it implied that once patients entered care, tumor stage had limited influence on treatment delay, indicating comparable urgency in managing both early and advanced cases thereafter. Another possible factor is that more complex surgery for advanced cancer may require additional preparation, potentially offsetting any time advantage [31], which appears to be supported by our findings that advanced cancer was not a protective predictor of prolonged TTI in either study periods. Since no studies have yet compared KC waiting times before and during the pandemic by cancer stage, further research is required to identify underlying reasons and to contextualize our findings.

To our knowledge, this study is among the first to assess the impact of COVID-19 on kidney cancer waiting times in Central and Eastern Europe. Our findings showed that while TTI and THI remained stable, TDI increased significantly among symptomatic patients during the pandemic, indicating that delays occurred primarily before the point of healthcare entry rather than during subsequent clinical management. These results highlight the importance of patient education and engagement to discourage delayed healthcare-seeking, even during periods of system disruption.

Advanced-stage disease was identified as a protective predictor against prolonged TDI before the pandemic and against prolonged THI during the pandemic. This pattern suggests that patients delayed seeking care irrespective of symptom severity during COVID-19, whereas advanced cases were appropriately prioritized once within the healthcare system.

As a secondary observation, median healthcare-related waiting times in our setting were longer than those typically reported internationally, suggesting potential regional challenges in healthcare access. This underscores systemic differences in care pathways and the need for targeted interventions to reduce delays. Further research is warranted to clarify the underlying causes of these disparities.

Overall, this study provides regionally relevant insights into kidney cancer care delivery, with implications for health-system optimization and patient-centered strategies during and beyond public health crises.