COVID-19: Heavy Toll From Ongoing Cancer Referral Delays

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Delays in cancer referrals caused by the COVID-19 pandemic and the ensuing shutdown in cancer services will lead to thousands of additional deaths and tens of thousands of life-years lost, suggest two new modeling studies from the United Kingdom.

Clearing the backlog in cancer diagnoses will require a coordinated effort from the government and the National Health Service (NHS), say the authors, inasmuch as services were already running at "full capacity" before the pandemic.

Both studies were published in The Lancet Oncology on July 20.

When the UK-wide lockdown to combat the COVID-19 pandemic was implemented on March 23, cancer screening and routine outpatient referrals in the NHS were suspended, and treatment of cancer patients either halted or slowed down.

Moreover, because of physical distancing measures, which are expected to continue for up to a year, urgent 3-week referrals for suspected cancer cases have fallen by as much as 80%.

To estimate the potential impact on cancer deaths, Ajay Aggarwal, MD, from the London School of Hygiene and Tropical Medicine, United Kingdom, and colleagues conducted a population-based modeling study.

They collected data on 32,583 patients with breast cancer, 24,975 with colorectal cancer, 6744 with esophageal cancer, and 29,305 with lung cancer. Patients were diagnosed between 2010 and 2012 and were followed to 2015.

The investigators used that data to estimate the impact of diagnostic delays resulting from 12 months of physical distancing.

For breast cancer, this would lead to a 7.9% to 9.6% increase in the number of cancer deaths within 5 years after diagnosis, or to 281–344 additional deaths.
For colorectal cancer, there would be a 15.3% to 16.7% increase in mortality over 5 years, or an additional 1445–1563 deaths.
For lung cancer, there would a 4.8% to 5.3% increase in mortality, or an additional 1235–1372 deaths.
For esophageal cancer, the mortality increase over 5 years would be 5.8% to 6.0%, leading to 330 to 342 additional deaths.
Across the four tumor types, 59,204–63,229 life-years would be lost because of physical distancing compared to the prepandemic era.

Resources Need to Be Increased

These additional deaths are not inevitable, the researchers suggest.

To prevent the increase in colorectal cancer deaths, for example, Aggarwal said, "It is vital that more resources are made urgently available for endoscopy and colonoscopy services, which are managing significant backlogs currently.

"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," he added in a statement.

"Therefore we need a whole system approach to avoid the predicted excess deaths."

Coauthor Bernard Rachet, PhD, also from the London School of Hygiene and Tropical Medicine, added that "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."

It will not be easy "to pin down the exact number of additional cancer deaths we expect to see over the coming years, but studies like this help us to understand the devastating long-term effect a pandemic like COVID-19 will have on the lives of thousands of cancer patients," commented Michelle Mitchell, chief executive of Cancer Research UK.

Underlining the "enormous backlog" of cancer care that has built up during the pandemic, she said: "Diagnosing and treating people swiftly is vital to give people with cancer the greatest chances of survival.

"The Government must work closely with the NHS to ensure it has sufficient staff and equipment to clear the backlog while giving patients the care that they need, quickly and safely," Mitchell added.

Increasing resources will not be easy. In an accompanying editorial, William Hamilton, MD, PhD, University of Exeter, United Kingdom, warns that many NHS imaging departments, for example, were "working at full capacity before the COVID-19 pandemic."

Consequently, they "might not be able to meet the increase in demand" resulting from the backlog in patients, especially as "the need to keep patients separate and to clean equipment has reduced their efficiency.

"The UK has had a long-term shortage of diagnostic capacity, although this shortage is not simply of equipment, but also of personnel, which is not so easily improved," he cautions.

Another Study, Similar Estimates

For the second study, Clare Turnbull, PhD, Institute of Cancer Research, London, United Kingdom, and colleagues obtained age- and stage-stratified 10-year cancer survival estimates for patients in England diagnosed with 20 common tumor types between 2008 and 2017.

They also gathered data on cancer diagnoses made via urgent 2-week referrals between 2013 and 2016. They estimate that 6281 patients were diagnosed with cancer of stages I–III per month.

Of those, 1691 (27%) would die within 10 years of their diagnosis, they found.

They then calculated that delays in 2-week referrals during a 3-month lockdown would lead to an average delay in presentation of 2 months per patient.

A resulting 25% backlog in referrals would lead to 181 additional lives and 3316 life-years lost. With a 75% backlog in referrals, an additional 276 lives and 5075 life-years would be lost.

The team says that additional diagnostic delays spread over 3 to 8 months after the lockdown could increase the impact of a 25% backlog in referrals to 401 additional lives and 14,873 life-years lost.

For a 75% backlog in referrals, the additional lives lost would rise to 1231, and the number of life-years lost would reach 22,635.

"Substantial additional deaths from diagnostic delays on top of those expected from delays in presentation — because many people are simply too afraid to visit their GP or hospital — are likely, especially if rapid provision of additional capacity, including technical provision and increased staffing, is not forthcoming," Turnbull commented in a statement.

The study by Aggarwal and colleagues was funded by the UK Research and Innovation Economic and Social Research Council. Several of the researchers were supported by Cancer Research UK and Breast Cancer Now. Turnbull reports receiving support from the Movember Foundation.

Lancet Oncol. Published online July 20, 2020. Study by Agarwal et al, Full text; Study by Turnbull et al, Full text; Editorial

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