London School of Hygiene & Tropical Medicine

The study highlights the need for urgent policy interventions to deal with the backlog of patients awaiting routine diagnostic services and to reduce the cancer death toll attributable to the COVID-19 pandemic.

The researchers call for policy makers to focus on three key areas: providing public health messaging that puts the risk of severe illness from COVID-19 into perspective compared with not seeking health-care advice for symptoms of cancer; providing evidence-based information to help health-care 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.

Dr Ajay Aggarwal, Associate Professor at the London School of Hygiene & Tropical Medicine (LSHTM), who led the research, said: “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.

“Whilst 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 2-week general practitioner (GP) referral or presenting to an emergency department. Since physical distancing measures were introduced on March 16, 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 existing English National Health Service (NHS) cancer registration and hospital administrative data on more than 93,000 cancer patients (aged 15-84) 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 March 16, 2020, to reflect the expected duration of disruption to diagnostic services.

The researchers 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% (1220–1254) rise in lung cancer deaths, and a 6% (330–342) rise in deaths from oesophageal cancer over the next 5 years.

Dr Aggarwal added: “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.”

These avoidable cancer deaths are projected to translate into 59,204 to 63,229 total years of life lost.

Co-author Professor Richard Sullivan from King’s College London said: “On average, for each avoidable cancer death due to diagnostic delay, 20 years of life will be lost. 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.

Co-author Dr Camille Maringe, Research Fellow at LSHTM, said: “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.

“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 LSHTM: “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.”

The study authors note that excess deaths across all cancer care is likely to be much higher. They emphasise that they only look at four cancer types and focus on delayed diagnoses. Therefore, it doesn’t account for delayed or cancelled cancer treatments for those already diagnosed with cancer.

The researchers also note several limitations including that they modelled the NHS as a whole despite variation across the country in terms of GP access, the burden of COVID-19, and the disruption to diagnostic services. They also note that the predicted survival of patients in 2020 will have slightly improved, whilst the proportions of patients presenting through different referral pathways has changed over time, which might affect the results.

This study was conducted by researchers from London School of Hygiene & Tropical Medicine, King’s College London, and Guy’s and St Thomas’ NHS Foundation Trust.

Publication

Maringe, Camille, Spicer, James, Morris, Melanie, Purushotham, Arnie, Nolte, Ellen, Sullivan, Richard, Rachet, Bernard, Aggarwal, Ajay. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis: a national population based modelling study. Lancet Oncology. DOI: 10.1016/S1470-2045(20)30388-0