ONCOLOGY
risk of severe illness from COVID-19 into perspective compared with not seeking healthcare advice for symptoms of cancer; providing evidence-based information to help healthcare workers manage the risks for patients with suspected cancer; and increasing both routine and urgent diagnostic capacity through increased working hours and referrals to any NHS hospital. “Our findings demonstrate the impact of the national COVID-19 response, which may cut short the lives of thousands of people with cancer in England over the next five years,” said Dr. Ajay Aggarwal from the London School of Hygiene & Tropical Medicine in the UK, who led the research. “While currently attention is being focused on diagnostic pathways where cancer is suspected, the issue is that a significant number of cancers are diagnosed in patients awaiting investigation for symptoms not considered related to be cancer. Therefore, we need a whole system approach to avoid the predicted excess deaths.” During the UK-wide lockdown to combat the COVID-19 pandemic, cancer screening and routine outpatient referral pathways (through which 30-40% of patients are diagnosed) were suspended. The only route to diagnosis for suspected cancer cases was via an urgent two-week general practitioner (GP) referral or presenting to an emergency department. Since physical distancing measures were introduced on 16 March, 2020, urgent referrals have fallen by as much as 80%. With some form of physical distancing expected to continue for up to a year, further negative impact on the lives of cancer patients is likely. In this study, researchers analysed
Disruption to cancer diagnosis services and people avoiding healthcare because of the COVID-19 pandemic could result in around 3,500 potentially avoidable deaths from the four main cancers in England by 2025.
existing English National Health Service (NHS) cancer registration and hospital administrative data on more than 93,000 cancer patients (aged 15-84 years) diagnosed in 2010-2012, to estimate the effect of delays in diagnosis on cancer survival for four main cancer types – breast, colorectal, oesophageal, and lung. They modelled the impact of reallocating patients from usual screening and non-urgent routine referral pathways (i.e. GPs and secondary care) to urgent and emergency pathways (which are associated with more advanced stage of disease at diagnosis), for a year after physical distancing measures were introduced on 16 March 2020, to reflect the expected duration of disruption to diagnostic services. The authors considered three reallocation scenarios which reflect what is being seen in the NHS during the COVID-19 crisis, providing best and worst case estimates to calculate the impact on net survival, additional deaths, and years of life lost (the number of years of life a person would have been expected to live had they not died of cancer) compared to pre-pandemic figures. The analyses suggest that delays in cancer diagnosis and changes in health-seeking behaviour could result in breast cancer deaths increasing by an
estimated 8-10% (equivalent to between 281 and 344 additional deaths by 2025) colorectal (bowel) cancer deaths by 15-17% (1445-1563), a 5% (1235-1372) rise in lung cancer deaths, and a 6% (330-342) rise in deaths from oesophageal cancer over the next five years. “Our findings estimate a nearly 20% increase in avoidable bowel cancer deaths due to diagnostic delays. To prevent this becoming a reality, it is vital that more resources are made urgently available for endoscopy and colonoscopy services which are managing significant backlogs currently, and that patients present promptly to their GP if they have any concerning gastrointestinal symptoms,” said Aggarwal. These avoidable cancer deaths are projected to translate into 59,204 to 63,229 total years of life lost. On average, for each avoidable cancer death due to diagnostic delay, 20 years of life will be lost,” added co-author Professor Richard Sullivan from King’s College London, UK. “These estimates paint a sobering picture and reflect the many young people who are affected by cancer in the prime of life during their most productive years.” The frontline of the cancer diagnostic system is GPs surgeries, and even as lockdown measures are being relaxed, presentation to primary care continues to be much lower than pre-pandemic levels. “As we slowly begin to resume normal life, we need accurate and measured public health messaging via a range of media channels tailored towards patients, GPs, and secondary care, that puts into perspective the risk of death from COVID-19 compared with that of delaying cancer diagnosis,” said co-author Dr. Camille Maringe from the London School of Hygiene & Tropical Medicine, UK. “Similarly, the healthcare community needs evidence-based information to adequately manage the risks of patients to the risks and benefits of contracting COVID-19 through different diagnostic procedures.” According to co-author, Professor
Bernard Rachet from the London School of Hygiene & Tropical Medicine, UK, to absorb the cancer patient backlog, the healthcare community also needs to “establish clear criteria to prioritise patients on clinical grounds, in order to maintain equitability in care delivery.”
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