DISRUPTION TO CANCER diagnosis services such as referrals and routine screening, and people avoiding healthcare because of the Covid-19 pandemic, could result in around 3,500 potentially avoidable deaths from the four main cancers in England by 2025, according to new research.

The findings of a study suggest that 3,291 to 3,621 lives could be lost to four main cancers in England (breast, colorectal, oesophageal, and lung) over the next five years due to delays in diagnosis caused by the pandemic.

On average, for each avoidable cancer death due to diagnostic delay, 20 years of life will be lost — reflecting a substantial proportion of deaths in younger or middle-aged people.

Authors of the study, which is published in the The Lancet Oncology journal, say urgent policy interventions are needed to manage the backlog of patients by increasing non-urgent routine diagnostic capacity through which 30-40% of patients are diagnosed with cancer.

The research suggests 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% (1,445–1,563), a 5% (1,235–1,372) rise in lung cancer deaths, and a 6% (330–342) rise in deaths from oesophageal cancer over the next five years.

The authors have called for policy makers to provide public health messaging that puts the risk of severe illness from Covid-19 into perspective compared with not seeking healthcare advice for symptoms of cancer; provide evidence-based information to help healthcare workers manage the risks for patients with suspected cancer; and increase both routine and urgent diagnostic capacity through increased working hours and referrals to any NHS hospital.

Speaking about the findings, Dr Ajay Aggarwal from the London School of Hygiene & Tropical Medicine in the UK, who led the research, said thousands of lives may be “cut short” over the next few 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 were suspended. The only route to diagnosis for suspected cancer cases was via an urgent two-week GP referral or presenting to an emergency department.

Since social distancing measures were introduced on 16 March, urgent referrals have fallen by as much as 80%, the research notes. 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 years) diagnosed in 2010-2012, to estimate the effect of delays in diagnosis on cancer survival for four main cancer types.

They modelled the impact of reallocating patients from usual screening and non-urgent routine referral pathways (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 16 March 2020, to reflect the expected duration of disruption to diagnostic services.

“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,” Aggarwal said.

60,000 years of life lost

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

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

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.”

Even as lockdown measures are being relaxed in the UK, presentation to primary care continues to be much lower than pre-pandemic levels.

“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,” co-author of the research, Dr Camille Maringe from the London School of Hygiene & Tropical Medicine, said.

The authors note that excess deaths across all cancer care are 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 authors also note several limitations with the research 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.

Backlog in referrals

In a second paper published in The Lancet Oncology journal, researchers examine the impact of backlog in cancer referrals during the UK lockdown on cancer survival.

Modelling different possible volumes of backlog, based on 10-year cancer survival estimates for patients (aged 30 years and older) in England for 20 common cancers diagnosed from 2008-17, they estimate deaths due to delays in diagnosis via the urgent two-week referral pathway during the Covid-19 crisis.

The model predicts 181 to 542 additional cancer deaths due to delay in patient presentation and referral during the three-month lockdown, and a further 401 to 1,231 deaths due to delayed diagnostic investigation dealing with this backlog of patients.

The findings also suggest that Covid-19-related delays in presentation, diagnosis, and subsequent treatment will result in additional deaths and years of life lost that vary widely according to patient age and type of cancer.

“Our estimates suggest that, for many cancers types, delays in diagnosis and treatment as short as two months will lead to a substantial proportion of patients with early-stage tumours progressing from having curable to incurable disease”, Professor Clare Turnbull from the Institute of Cancer Research in the UK, who led the research, said.

“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 because they are worried about catching Covid-19 are likely, especially if rapid provision of additional capacity, including technical provision and increased staffing, is not forthcoming.”