We need to count the previously invisible cost of covid-19 on people with cancer

The covid-19 pandemic has had a dramatic global health impact particularly in countries which are demographically older and with populations carrying significant co-morbidities. While the focus has been on direct mortality caused by covid-19 there has been little attention paid to the indirect impact on other significant health conditions, such as cancer, caused by national measures to contain the SARS-Cov-2 virus spread, so-called non-pharmaceutical interventions (NPI). NPI’s encompass a wide range of measures including “hard lockdowns” and there is a growing realization that particularly national or regional lockdowns, come at a cost to wider health and welfare of societies. 

Following the first wave of covid-19 hospitalizations and mortality from March onwards a range of interlocking barriers to timely presentation, diagnosis and treatment of cancer have become acutely apparent. There have been reductions in patients seeking help for their symptoms, including a huge decline in referrals from primary care and substantial delays in diagnosis due to cessation of diagnostic services. A recent study from the UK, predicted that for four common types of cancer (breast, bowel, lung and oesophageal cancers), delays in diagnosis due to the covid-19 pandemic will result in approximately 3500 avoidable cancer deaths, equating to 60,000 years of life lost reflecting the younger age profile of many cancer patients. [1] Yet, these figures do not consider the impact of delays in initiation of treatment or changes in treatment schedules.

For instance, dramatic backlogs for time sensitive surgeries have also mounted due to NPI measures in the first-wave lockdown. [2] In the Canadian province of Ontario, it is estimated that it would take 14 weeks to clear the surgical backlog if only the time sensitive cases were tackled, and 84 weeks for the whole backlog. [2] The pandemic has essentially introduced higher friction into the cancer care system that is being translated into diagnostic and treatment delays. This has not been helped by a failure to provide public health messaging that conveys accurately the magnitude of risks of severe illness from SARS-CoV-2 infection compared with the risks of not seeking healthcare-advice if symptomatic from cancer or other conditions. In addition, clinicians still need information to support and manage the risks of undertaking diagnostic and surgical procedures during the pandemic. Without this, health seeking behaviour will continue to be affected as will the ability to scale up diagnostic and treatment services for cancer and other acute and chronic conditions. 

What has been clear in many country’s responses to covid-19 is the inability to weigh the direct impact of the pandemic, with the wider acute and long term impact on health and welfare outcomes of conditions such as cancer which are exquisitely sensitive to changes in social and health systems and to patient behaviour. This necessitates data that is complex to collect, takes time and requires careful analysis, but sadly the pandemic has thrown into stark relief this clear evidence gap. 

At the start of the pandemic the focus was, unsurprisingly, on managing and prioritizing patients under conditions of great uncertainty as to who was most at risk and what treatments might potentially lead to severe covid-19. [3,4] However, it also become rapidly apparent that treatment delays especially to cancer surgery, were also occurring as staff were redeployed, intensive care capacity became limited, and fewer procedures could be performed due to the requirement for full PPE and robust cleaning protocols between patients. Yet, there was no formal quantification of the potential impact of treatment delay across most major cancer types and treatments including radiotherapy. 

The results of our systematic review on this topic are therefore both sobering and staggering. [5] Across cancer surgery, radiotherapy and systemic treatments and for all seven cancers that we considered (bladder, breast, colon, rectum, lung, cervix, and head and neck), delays of only 4 weeks were associated with a greater mortality impact.  For the UK alone, a 12 week surgery delay over a year of lockdown and backlog recovery for breast cancer alone could translate into over 1400 additional deaths, not counting the downstream effects of any systemic therapy or radiotherapy delay leading to further mortality or disease recurrences, and other societal and health impacts of delay. 

This work fills a significant gap between models and estimates for diagnostic delay and longer term cancer mortality impacts due to economic declines, providing a conceptual framework and data to inform pandemic NPI modelling for high level policy-making and prioritization of cancer services during mitigation and recovery phases. [1,6] Shutdown of cancer services in the early phase of the pandemic was necessary due to substantial uncertainty of risks and to facilitate system preparedness. However, with cumulative knowledge, we now have less uncertainty about risks and need to be more mindful of trade-offs and unintended consequences.  

Covid-19 is not an isolated biological entity, but aggregated into wider health epidemics. Each country will need to create their own models for their systems, but crucially real data on real cancer patients is what is needed. Consequently, this pandemic has taught us that we need to build much better health information systems, cancer included. We also need to consider the risk of widening inequalities in cancer outcomes, that risk becoming entrenched due to increased risk factor burden, unemployment, income inequality, and the ability of affluent groups to self-navigate to quicker cancer diagnosis and receiving timely treatment compared to deprived groups.  

Undoubtedly the pandemic’s impact on cancer care and outcomes will be felt long after the virus reaches global equilibrium. We now need to count the previously invisible cost of covid-19 on people with cancer. 

Timothy P Hanna, Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen’s University; Department of Oncology, Queen’s University; Department of Public Health Sciences, Queen’s University. Competing interests: unrestricted research grant from Roche on unrelated topic.

Ajay Aggarwal, Department of Clinical Oncology, Guy’s & St Thomas’ NHS Trust, London, UK; Institute of Cancer Policy, King’s College London, London, UK; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK. No conflicts of interest.

Christopher M Booth, Division of Cancer Care and Epidemiology, Cancer Research Institute at Queen’s University; Department of Oncology, Queen’s University; Department of Public Health Sciences, Queen’s University; Department of Medicine, Queen’s University. No conflicts of interest.

Richard Sullivan, Institute of Cancer Policy, King’s College London, London, UK. No conflicts of interest. 

References:

1. Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. The Lancet Oncology. 2020;21(8):1023-34.
2. Wang J, Vahid S, Eberg M, Milroy S, Milkovich J, Wright FC, et al. Clearing the surgical backlog caused by COVID-19 in Ontario: a time series modelling study. CMAJ. 2020.
3. Hanna TP, Evans GA, Booth CM. Cancer, COVID-19 and the precautionary principle: prioritizing treatment during a global pandemic. Nat Rev Clin Oncol. 2020;17(5):268-70.
4. Lee LY, Cazier JB, Angelis V, Arnold R, Bisht V, Campton NA, et al. COVID-19 mortality in patients with cancer on chemotherapy or other anticancer treatments: a prospective cohort study. Lancet. 2020;395(10241):1919-26.
5. Hanna TP, King WD, Thibodeau S, Jalink M, Paulin GA, Harvey-Jones E, et al. Mortality due to cancer treatment delay: systematic review and meta-analysis. Bmj. 2020;371 available online.
6. Maruthappu M, Watkins J, Noor AM, Williams C, Ali R, Sullivan R, et al. Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis. Lancet. 2016;388(10045):684-95.