With hospitals again beginning to see strain from the ongoing coronavirus pandemic, some NHS trusts are already deferring surgeries and investigative procedures further into the future to direct resources to acute care and ‘substantial demand’ for accident and emergency services. Whilst SARS-CoV-2 (and COVID-19 in itself) ultimately pose great risk to cancer patients in an immunological sense, there are also larger, yet subtle secondary implications from high community transmission. With the UK government stepping out into untested waters in a brave new world, community transmission of COVID-19 through the Delta variant has kept a circa 30K case per day bolus throughout the summer of this year. The implications for cancer patients (and not only in the immediate sense) is that again, a ‘hard winter’ will surely push more attention away from essential care, testing and referral for suspected cancer cases and further impact those awaiting diagnosis, surgery or treatment. As the pandemic quickly approaches the 2 year anniversary, we hereby assess the evidence of impact on oncology as a field, and ultimately the impact reduced service has had on patients and families nationwide.
As reported by Nuffield earlier this year, the NHS has a lofty goal of 55,000 patients each year to survive cancer after treatment and achieve an acceptable life expectancy thereafter (i.e. 5 years+ post diagnosis) – something set before the term ‘pandemic’ had even entered our collective consciousness. In April 2020, data suggests two week referrals (reserved for suspected cancer with several red flag symptoms) was down almost 100% on normal levels. This perhaps is no surprise, given the absence of data on coronavirus, its method of infection and limited public health guidance. As of April this year, urgent referrals for cancer had all but stagnated to lower than pre-pandemic levels, and some remain 30-40% lower. The implications are massive – if a system is unbeknownst to patients who have cancers, these cancers progress to later stages risking significant mortality, emergency presentation, further strain on the health system and vastly reduced life expectancy for those with high-severity cancers.
Slow increases in diagnosis have occurred for only two cancers, breast and skin. This perhaps is not surprising given the (relative) ease of diagnosis for breast and skin cancers – with skin samples often taken without extreme intervention, and the wealth of breast screening clinics and services across the UK. What is much more alarming is the rift in referral and diagnostic rate-recovery between those easily diagnosed and those which require intensive scanning and ‘hands-on’ diagnoses like lung and urological cancers. These cancers of course are notorious for requiring severe intervention, often through surgery, or intensive chemotherapy and radiological treatment. As of February of this year, the rate of change for consultant appointments issued for these suspected cancers has shot up across all cancer types.
Positive news comes in the form of treatment rates for all cancers growing steadily to above pre-pandemic levels due to dedication from services and oncologists, public health measures (including masks, vaccinations and isolation) and increased availability of GPs to offer appointments and some face-to-face services. A lofty goal has been set to significantly outrun rates of referral, diagnosis and treatment by 2022 to address the backlog of those waiting for cancer care. Those who have suspected cancer, for example, and do not have red flag symptoms (pain, bleeding, weight loss, anaemia etc) are typically seen in a non-urgent fashion and within 2 months. There is a further target for 85% of patients to begin treatment from an urgent referral within 8 weeks of diagnosis, something set before the pandemic. Diagnosis for certain forms of cancer were stopped and limited due to the nature of the procedure, writes The Lancet – with those causing aerosols and increasing the risk of transmission such as endoscopies, colonoscopies and certain types of oral interventions down 90% on normal levels.
The real penalty for cancer care due to the pandemic is the reduction in referrals which leaves many in the community with potentially life threatening cancers that have the capacity to metastasise and progress to late stage. This of course has knock on effects for palliative care and wider public health for community teams who must manage terminally ill patients for whom intervention is often deemed (in vain?). Currently 7 in 100 urgent referrals ultimately end up as cancer and improvements in technology will provide a reduction in this number as screening programmes increase and catch cancers at earlier stages.
However, many anecdotal and now data-backed reports suggest many patients throughout the pandemic who had urgent referrals did not receive a hospital appointment with consultant within the NHS set 2 week window (from referral). Recent cases in The Telegraph provide vignettes of patients diagnosed with late stage bowel cancer due to colonoscopy delays, patients with coughs eventually ending up with lung cancer when CT scans were not on time and some surgeries which a month later could have been not enough. The Lancet again reports symptoms of lung cancer being confused with COVID-19 and subsequent health campaigns arranged to address this.
Fewer emergency department attendees again will have had warning signs missed, with the number of people predicted to of neglected going to A&E as high as 26 million. As the pandemic rumbles on, and with an uncertain winter ahead of us, we will surely see disruption continue in the health service as some NHS trusts begin cancelling elective surgery once more. Only time will tell how big a toll coronavirus has had on wider public health, and many experts believe excess mortality will not mop up those deaths from cancer accounted for by reduced access to testing, services and clinicians. With vaccination coverage wider and emboldened going into winter, less disruption than last year may be expected. Yet, with public health policies winding down and borders opening, the eternal threat of a new variant could serve to scupper the governments hastily laid plans.