The Covid effect: clearing the cancer backlog

In can­cer treat­ment, ear­ly diag­no­sis saves lives. As we recov­er from the coro­n­avirus out­break, pan­dem­ic-dri­ven delays look set to result in thou­sands of addi­tion­al deaths. 

The true num­ber of can­cer casu­al­ties due to Covid-19 will only become clear in the com­ing years, but one esti­mate by Uni­ver­si­ty Col­lege Lon­don and DATA-CAN: The Health Data Research Hub for Can­cer puts the addi­tion­al UK can­cer death toll at as high as 18,000 over the next 12 months.

Data from DATA-CAN also shows that dur­ing the first wave of the pan­dem­ic in 2020, 70% of peo­ple with sus­pi­cious symp­toms were not referred to spe­cial­ist can­cer ser­vices, while 40% of chemother­a­py treat­ments were delayed.

The Depart­ment of Health and Social Care (DHSC) says can­cer diag­no­sis and treat­ment has remained a top pri­or­i­ty through­out the pan­dem­ic. The major­i­ty of patients referred by a GP see a can­cer spe­cial­ist with­in two weeks, DHSC claims, while more than 2 mil­lion urgent refer­rals have tak­en place and 570,000 peo­ple have been receiv­ing treat­ment since the pan­dem­ic began.

We hope the pan­dem­ic will prompt recon­fig­u­ra­tion of can­cer ser­vices to bet­ter pro­tect future deliv­ery in the face of the next cri­sis

In March 2021, urgent refer­rals by a GP for can­cer were the high­est record­ed since can­cer data col­lec­tion began, with an aver­age of more than 10,000 patients referred each work­ing day. That is more than 232,000 refer­rals in total, up by 26.4% com­pared to the pre­vi­ous March.

But accord­ing to Can­cer Research UK (CRUK), an esti­mat­ed 3 mil­lion few­er peo­ple were screened for can­cer between March and Sep­tem­ber last year. As a result, that means around 9,200 few­er patients start­ed treat­ment in Eng­land alone, and 45,000 few­er can­cer patients were diag­nosed or treat­ed between March 2020 and March 2021.

Anoth­er way of mea­sur­ing the impact of Covid is that there were 330,000 few­er GP urgent refer­rals between March 2020 and March 2021, 13% down on the pre­vi­ous 12 months, cre­at­ing a back­log that over-stretched staff are now try­ing to deal with.

The impact on survival rates

“The impact on can­cer of the pan­dem­ic has clear­ly been dev­as­tat­ing,” says Kru­ti Shrotri, head of pol­i­cy devel­op­ment at CRUK. “We fear can­cer sur­vival rates will decline for the first time. There are lots of peo­ple out there who have can­cer but don’t know it.”

Clare Turn­bull, pro­fes­sor of trans­la­tion­al can­cer genet­ics at London’s Insti­tute of Can­cer Research, says peo­ple who have been scared to vis­it their GP or go to the hos­pi­tal for fear of catch­ing Covid are pre­sent­ing lat­er with worse symp­toms and more advanced can­cer that may be more dif­fi­cult to treat. 

“We can expect the result­ing delays to diag­no­sis and treat­ment will lead to sub­stan­tial avoid­able deaths across dif­fer­ent can­cer types in com­ing years,” she says. Any sig­nif­i­cant delay in pre­sen­ta­tion, diag­no­sis or treat­ment could make a crit­i­cal dif­fer­ence, she says, mean­ing the patient miss­es the win­dow for their can­cer to be picked up and treat­ed while it can be cured and they have a nor­mal life expectan­cy. 

“The dan­ger is if you pass through that win­dow then your can­cer turns out to have pro­gressed and is no longer cur­able.”

Ini­tial mod­el­ling ear­ly in the pan­dem­ic demon­strat­ed that if each patient across 20 com­mon can­cer types referred along the urgent refer­ral path­way expe­ri­enced a total delay to treat­ment of one month com­pared to pre­vi­ous years, this would result in 1,400 lives lost a year and 25,800 life-years lost. A six-month delay would result in 9,300 lives and 173,500 life-years lost, says Turn­bull. 

The delay expe­ri­enced by each patient with a poten­tial­ly cur­able can­cer is dif­fi­cult to deter­mine as it’s a com­bi­na­tion of their delay in get­ting a GP appoint­ment, delay in refer­ral, delay in hos­pi­tal diag­nos­tic tests, delay in addi­tion­al and often com­plex imag­ing stud­ies to dis­cov­er the extent or stage of the can­cer, delay in surgery and delay in any chemother­a­py or radio­ther­a­py accom­pa­ny­ing the surgery. 

The issue of late-stage diagnosis

“Data is com­ing through show­ing, as pre­dict­ed, an upwards shift in the stage at which can­cers have been diag­nosed over the past 14 months. We know this will equate to more deaths,” says Turn­bull.

She acknowl­edges NHS staff have worked tire­less­ly to rein­state can­cer ser­vices as rapid­ly as pos­si­ble. How­ev­er, there is still a major back­log of patients await­ing out­pa­tient appoint­ments, inves­ti­ga­tions and surg­eries.

There have been approx­i­mate­ly 40,000 few­er can­cer diag­noses over the last 14 months, Turn­bull says, so dur­ing the com­ing months the NHS is like­ly to be deal­ing with more can­cer pre­sen­ta­tions than nor­mal, while also work­ing at 80% of its usu­al capac­i­ty due to social dis­tanc­ing and oth­er infec­tion-con­trol mea­sures. 

“Covid-19 has caused an acute-on-chron­ic cri­sis in can­cer care. Dur­ing the rise of the pan­dem­ic in spring 2020, unprece­dent­ed pres­sure on hos­pi­tal beds and inten­sive care units, rede­ploy­ment of staff, cau­tion regard­ing trans­mis­sion in hos­pi­tals, reduced pri­ma­ry care access and pop­u­la­tion lock­down com­bined in a per­fect storm, dra­mat­i­cal­ly dis­rupt­ing UK can­cer care path­ways,” Turn­bull says.

“How­ev­er, the pan­dem­ic arose against a back­drop of can­cer out­comes already dete­ri­o­rat­ing com­pared to coun­tries in the Organ­i­sa­tion of Eco­nom­ic Co-oper­a­tion and Devel­op­ment. This decline is due to chron­ic, wors­en­ing capac­i­ty issues, main­ly relat­ing to short­ages in can­cer pro­fes­sion­als, from nurs­es, doc­tors and sur­geons to radi­og­ra­phers, clin­i­cal sci­en­tists and pathol­o­gists.”

There’s nev­er a good time to have can­cer, but the pan­dem­ic is a bad time

Lung and prostate can­cers in par­tic­u­lar are going undi­ag­nosed, says Shrotri. “A cough may be a sign of Covid, but it could also be lung can­cer,” she says. Breast can­cer treat­ment has also been impact­ed as screen­ing pro­grammes were paused, so many cas­es of breast can­cer went undi­ag­nosed.

The UK has three can­cer screen­ing pro­grammes for breast, bow­el and cer­vi­cal can­cer. Because of Covid, invi­ta­tions and fol­low-up appoint­ments have been delayed.

But can­cer surgery has been hard­est hit. “We saw a 40% drop in surgery, main­ly because of the need to pri­ori­tise inten­sive care beds for Covid patients,” says Shrotri. “There’s nev­er a good time to have can­cer, but the pan­dem­ic is a bad time. Many patients thought they were for­got­ten.”

It has been “dev­as­tat­ing to see diag­no­sis and treat­ment paused and delayed”, Shrotri con­tin­ued, with some patients dying or cura­tive treat­ment now com­ing too late. 

“Over the past cou­ple of months, more peo­ple than usu­al are com­ing through the sys­tem, so the NHS is start­ing to tack­le the back­log, but there’s a very long way to go. We’re still not see­ing as many peo­ple as we would expect.”

Building back smarter

Mark Lawler, pro­fes­sor of dig­i­tal health at Queen’s Uni­ver­si­ty Belfast and sci­en­tif­ic lead at DATA-CAN, says the data sug­gests can­cer ser­vices now need to be oper­at­ing at 130% of pre-Covid lev­els.

“Get­ting back to 100% is not enough,” he says. “It’s soul destroy­ing when you see the num­bers and every one of those num­bers rep­re­sents a per­son.”

While the pan­dem­ic has shown that our can­cer ser­vices are not as resilient as we thought, “this is a huge oppor­tu­ni­ty to reimag­ine can­cer ser­vices and build back smarter using data with an inno­v­a­tive approach”, he adds. 

Lawler, who is also co-chair of the Euro­pean Can­cer Organisation’s Spe­cial Net­work on Covid-19 and Can­cer, says the pan­dem­ic back­log calls for a pan-Euro­pean approach.

The organisation’s sev­en-point plan aims to address that back­log by restor­ing con­fi­dence in can­cer health ser­vices; tack­ling med­i­cines, prod­ucts and equip­ment short­ages; fill­ing gaps in the can­cer work­force; employ­ing inno­v­a­tive tech­nolo­gies and solu­tions to strength­en can­cer sys­tems and pro­vide opti­mal care for patients; embed­ding data col­lec­tion and rapid deploy­ment of can­cer intel­li­gence to enhance pol­i­cy deliv­ery; and secur­ing and sus­tain­ing deep­er long-term Euro­pean health co-oper­a­tion.

“It’s very much a pan-Euro­pean plan rather than a Euro­pean Union plan; can­cer knows no bor­ders,” says Lawler.

Turn­bull at the Insti­tute of Can­cer Research adds: “It is a grave mis­take to believe these issues can all be solved by a year or two’s extra fund­ing for ‘Covid recov­ery’. We des­per­ate­ly require a long-term cross-par­ty plan for can­cer care to allow us to turn around the down­ward tra­jec­to­ry of our can­cer out­comes. Only then can we ensure we have can­cer ser­vices we can be proud of on a nor­mal day, but which are resilient to future dis­rup­tors, be it sea­son­al flu or the next pan­dem­ic.”

Levelling up inequalities

Pro­fes­sor Charles Swan­ton, chief clin­i­cian for CRUK, says that build­ing back should also mean lev­el­ling up, address­ing “long­stand­ing, unac­cept­able can­cer inequal­i­ties” across the UK that every year equate to around 20,000 more can­cer cas­es.

“There have been huge break­throughs in the last decade in life-sav­ing can­cer research, for exam­ple in can­cer immunother­a­py, but we need the break­throughs of tomor­row,” he says.

Invest­ment is need­ed on mul­ti­ple lev­els: work­force, equip­ment, pri­ma­ry care, rapid diag­nos­tic cen­tres and the clin­i­cal research sci­en­tists who will help deliv­er med­ical break­throughs. 

“If the right approach is tak­en, the UK can emerge from this pan­dem­ic with a can­cer path­way that is more inno­v­a­tive, flex­i­ble and bet­ter equipped to save more lives,” says Swan­ton.

We have learnt much from our lack of readi­ness for the Covid-19 pan­dem­ic, says Turn­bull. A key ele­ment of future pan­dem­ic plan­ning will be pre­de­fined pro­to­cols and process­es to ensure the safe­ty of staff and can­cer patients from infec­tion, along with ratio­nal pri­ori­ti­sa­tion for deliv­er­ing med­ical pro­ce­dures. 

“Can­cer path­ways are com­plex and thus frag­ile; we need to ensure they remain resilient to future extrin­sic dis­rup­tion,” accord­ing to Turn­bull. “Coun­tries around the world and else­where in Europe have shown stand­alone facil­i­ties can help to main­tain can­cer ser­vices along­side over­bur­dened hos­pi­tals. We hope the pan­dem­ic will prompt recon­fig­u­ra­tion of can­cer ser­vices to bet­ter pro­tect future deliv­ery in the face of the next cri­sis.”

The DHSC says: “The NHS has pub­lished its plan to recov­er can­cer ser­vices, and we’re pro­vid­ing an extra £1 bil­lion to boost diag­no­sis and elec­tive treat­ment in the year ahead as well as invest­ing £325 mil­lion in NHS diag­nos­tic machines to improve the expe­ri­ence of can­cer patients.”

This is a huge oppor­tu­ni­ty to reimag­ine can­cer ser­vices and build back smarter

The gov­ern­ment response is head­ed by Pro­fes­sor Peter John­son, nation­al clin­i­cal direc­tor for can­cer, who heads the Can­cer Recov­ery Task­force, which reports to the Nation­al Can­cer Board. The board over­sees deliv­ery of the NHS Long Term Plan’s ambi­tions to diag­nose 75% of can­cers at stage 1 or 2 and for 55,000 more peo­ple to sur­vive can­cer for five years or more by 2028.

NHS pri­or­i­ties and oper­a­tional plan­ning guid­ance from March 2021 sets out tar­gets to return to 85% of 2019–20 lev­els by July 2021 for elec­tive treat­ments and for this to rise in the autumn. The aim is also to meet the increased lev­el of refer­rals and treat­ment required to address the short­fall in the num­ber of first treat­ments by March 2022.

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Cancer care threatened by staff burnout

The NHS faces a wors­en­ing staffing cri­sis as doc­tors, nurs­es and oth­er health­care pro­fes­sion­als are inun­dat­ed with record num­bers of can­cer patients whose diag­no­sis has been delayed by the pan­dem­ic.

Deal­ing with the delayed refer­rals, diag­no­sis and treat­ment will mean “squeez­ing more out of exhaust­ed NHS staff”, says Clare Turn­bull, pro­fes­sor of trans­la­tion­al can­cer genet­ics at the Insti­tute of Can­cer Research. “The­atre staff, who already work many week­ends, are being asked to come in on extra Sat­ur­days and Sun­days to per­form catch-up the­atre lists.”

There is grow­ing con­cern about staff burnout and fears that the pan­dem­ic may pre­cip­i­tate a wave of depar­tures or ear­ly retire­ment of health­care work­ers. In com­bi­na­tion with Brex­it and greater bar­ri­ers to immi­gra­tion, the NHS may find work­force short­ages wors­en­ing just when it needs to deliv­er increased lev­els of can­cer ser­vices.

It takes five to 10 years to train a nurse and 10 to 15 years to train a doc­tor, Turn­bull notes; expand­ing train­ing places now for med­ical, nurs­ing and oth­er health­care pro­fes­sion­als will only deliv­er more staff in a decade or so. 

“We can­not con­tin­ue to pro­cras­ti­nate, nor seem­ing­ly can we be so con­fi­dent in our exist­ing mod­el of acquir­ing over­seas-trained clin­i­cal staff from oth­er stretched health­care ser­vices.”

Kru­ti Shrotri, head of pol­i­cy devel­op­ment at Can­cer Research UK, says CRUK has been call­ing on the gov­ern­ment to invest in more NHS staff for many years. “Now it’s a top pri­or­i­ty for the com­ing Spend­ing Review,” she says. “The increase in capac­i­ty need­ed is going to be sub­stan­tial.”

How­ev­er, invest­ment in staff will take time to come through, she says – the NHS needs to step up to the chal­lenge now. 

“There need to be more inno­v­a­tive ways of deal­ing with the back­log.”

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