Coronavirus Has a Massive Impact on Cancer Care
Matt Boente MD shares this important article from Bloomberg:
New figures from the U.K.’s National Health Service highlight the problems being caused by the Covid-19 pandemic.
Therese Raphael June 14, 2020, 11:00 PM PDT
It has been a while since I thought back to that week in 2012 when I received news that three close family members had been diagnosed with cancer — two in my household. Newly published figures on how Covid-19 has delayed cancer referrals and treatments brought the memory back. I’m grateful those cases didn’t arise in the middle of a pandemic, but alarmed at the implications for those fighting cancer now.
New data from the U.K.’s National Health Service showed how the focus on Covid-19 has been impacting cancer care. Urgent cancer referrals fell by 60% in April compared with the same month last year. That’s a major concern given how important early diagnosis is to successful treatment and cancer survival rates. This, and other recent data, are a grim reminder that the NHS’s much-lauded response to the pandemic has come at a cost.
How this will affect the U.K.’s already lagging cancer survival rates depends on how quickly the health-care system can restore capacity and deal with a backlog of cases. But the data suggest we had better brace for bad news.
A study published in April modeled the number of excess deaths likely to occur among people with cancer and other problems during Covid-19; the results suggest that an additional 18,000 people with cancer in the U.K. could die in the next 12 months. The researchers also analyzed data from the U.S. and estimated the country could see 33,890 excess deaths from cancer.
At every stage of what is referred to as a patient’s cancer pathway, Covid-19 has slowed things. Even among patients who did get a referral, the proportion who were then seen within the two-week target time was at its lowest level ever in April. The median length of time patients waited for treatment was 12.2 weeks, with more than a million patients waiting more than 18 weeks. There was also an 18% decline in the number of people starting cancer treatment following a referral.
Missing Cancer Patients
Urgent cancer referrals in April were down by about 60% compared to April 2019
Source: NHS England
Note: Oct. 2019-April 2020 data is provisional.
Cancer remains the second biggest cause of death globally (after cardiovascular diseases), and cases are rising in many countries. Despite big improvements in prevention, the number of people diagnosed with cancer each year is set to grow rapidly in the U.K. Cancer Research UK, a charity, estimates that one in two of those born after 1960 will get the disease.
Over the past decade, cancer care has been steadily improving in Britain — albeit from a low baseline. There is now a more ambitious national cancer strategy, better data reporting, more investment and greater public awareness. There are targets for the time between a referral and receiving a diagnostic test (two weeks), receiving a diagnosis (28 days) and starting treatment (no more than 62 days from the date of referral).
Even so, the U.K. lags behind almost all other advanced countries in one- and five-year survival rates for most cancers. Now the pandemic threatens to set back cancer care considerably.
Cancer Survival Rates
The U.K. lags behind other OECD nations on five-year cancer survival rates
Note: Five-year cancer survival rates, 2010-2014.
“We have improved because there has been pretty steadfast focus and support for cancer treatment in this country, but the reality is that Covid will have hit very hard,” says Sarah Woolnough, an executive director at Cancer Research UK. Key to Britain’s progress over the past decade, she notes, was reducing the lag time for diagnostic services; and yet that critical first step on the cancer pathway has been disrupted by Covid-19.
Britain has national screening programs to test for breast, cervical and bowel cancers. These weren’t officially suspended in England, but the NHS stopped sending out screening invitations, notes Woolnough. Unsurprisingly, there was a 78% drop in breast cancer referrals in April from the year before. Overall, Cancer Research UK estimates 3,800 cancers would have been diagnosed through screening during the first 10 weeks of lockdown. The charity also estimates that during those 10 weeks, 12,750 fewer patients received cancer surgery, 6,000 fewer had chemotherapy treatments and 2,800 missed radiotherapy.
The Other Testing Shortfall
March and April saw a huge drop in the number of tests used to diagnose conditions such as cancer
Source: NHS England
Note: Data tracks 15 different types of diagnostic tests including MRI scans and colonoscopies.
More worryingly, Covid seems to have deterred people with symptoms from seeking help. “We spent the last decade saying to people that if you suspect symptoms, please go check it out. Covid has set that effort back,” Woolnough says. Some are worried about wasting the doctor’s time during a crisis; many fear for their safety.
Getting people back to seeking these services will take clearer guidance from the government and a protocol for testing patients and health-care providers for Covid-19. Woolnough estimates that it would take up to 37,000 tests a day for providers to operate safely. So far the government hasn’t published guidance on testing cancer patients.
Among the most vulnerable cancer patients are those who receive stem cell transplants because of their highly compromised immune systems. Henny Braund, chief executive of Anthony Nolan — a U.K. charity that matches stem cell or bone marrow donors to patients with blood cancers — told me they’ve seen a 25% reduction in the number of transplants. “There needs to be some thought about how that backlog is going to be dealt with, in ensuring we’ve got the right workforce in place, the right PPE and testing for patients and staff,” she says. All three are in short supply.
Even London’s lucrative private hospital market, where a quarter of revenues come from the cancer care, is seeing fewer patients. Robert Marcus, a consultant haematologist with the private provider HCA Healthcare, says the number of patients he’s seeing now is a lot lower than six months ago and the chemotherapy units where he works are operating at 50% to 60% capacity. “You can’t necessarily put the same number of patients on a surgical list or a radiologist’s list than you did because you can’t have the patients mixing in waiting rooms and you have to be even more scrupulous about the cleaning of the various environments,” he says.
Treatment plans are also impacted. The big post-Covid change, apart from capacity constraints, is that providers now need to weigh the risk of giving immune-compromised patients treatment that will make them more vulnerable to complications from Covid-19.
Between a Rock and a Hard Place
Health care charities have been forced to cut staff and activity, despite an expected increase in need
Source: Pro Bono Economics
There is another potential hit to the U.K.’s cancer-fighting effort: a loss of funding. Charities fund 60% of all cancer research in the U.K. and 40% of all medical research; they also provide vital services from nursing to support lines and financial aid for patients.
Cancer Research UK spends more than 400 million pounds ($502 million) a year supporting research at some 90 different institutions. Its income is from private donations and the proceeds of its 600 charity shops, which have been closed in the lockdown. The charity is projecting a 25% drop in income this year and has already made a 44-million pound cut to its research portfolio. Anthony Nolan’s Braund says it expects a fall of a quarter to a half of gross income this year.
If we’re looking for silver linings, the Covid crisis seems to have sped up the adoption of more targeted, simplified therapies for a host of cancers, which can mean fewer trips to the hospital or less toxic treatment. It has resulted in some useful partnerships with private hospitals. And many doctors have said private hallelujahs to the way the crisis has cut bureaucracy. There is now an opportunity for a high-level rethink of how health care is delivered; a new NHS Confederation report calls for such a “reset.”
Not all delays or changes to treatment protocols mean shortened lives, either. Many people can safely have treatment postponed or changed. My father-in-law’s prostate cancer in 2012 was treated with radiation; that’s generally a slow-moving cancer and waiting out a pandemic may have been fine. However, he died seven years later, after battling a far more aggressive cancer that needed frequent interventions. (The other two cancers in my family were also not ones where waiting was a great option; one treatment was curative and the other bought a couple more quality years of life.)
The virus has undoubtedly set back the U.K.’s cancer fighting cause. But some things will make a difficult situation worse: A lack of Covid-19 testing capacity, delays to contact tracing and unclear guidance from the government were repeatedly mentioned to me. The longer it takes to resume services, the greater the chance that Britain will lurch from one health crisis straight into another.
— With assistance by Lara Williams
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
To contact the author of this story:
Therese Raphael at email@example.com
To contact the editor responsible for this story:
Nicole Torres at firstname.lastname@example.orgBefore it’s here, it’s on the Bloomberg Terminal.