Covid-19 has had a personal impact on me. On 29 March 2020, I lost my uncle to covid-19. My colleague Eduard Vrdoljak, while consoling me for my loss, indicated that in Croatia “people were fearing a covid-19 diagnosis more than a cancer diagnosis.” An aspect of this that worried us was the realisation that government-backed measures to combat covid-19 could have destablised cancer services across Europe. We wrote an opinion piece in the European Journal of Cancer, highlighting how a repurposed pandemic-focussed health service could compromise cancer screening, delay cancer diagnoses, and precipitate cancellation/postponement of cancer treatments.  Looking back at that publication, which appeared online in April 2020, I’m sad to say we were proven right by what subsequently transpired.
But where were the data to either refute or support Eduard’s claim? Through DATA-CAN, the UK’s Health Data Research Hub for Cancer, and University College London, we reached out to hospital trusts UK-wide, capturing data in “real time” to measure covid’s impact on cancer services and patients. On 29 April, exactly one month after my uncle died, we posted a scientific paper online, reporting results of our rapidly-completed research.  The findings were so worrying that before posting online, we shared them with the chief medical officers in the four UK nations, the National Clinical Director for Cancer, and SAGE—the UK’s Scientific Advisory Group for Emergencies.
We found that there was a 76% drop in urgent referrals for people with suspicious symptoms potentially indicating cancer (e.g. lump on their breast, difficulty swallowing, blood in their pee or poo). But what does that actually mean? Worryingly, it reveals that 7 out of 10 people with suspicion of cancer were not being seen by cancer diagnostic specialists. For cancer patients, our results were equally concerning; 40% reduction in attending chemotherapy clinics meant that for 4 out of 10 cancer patients, their chemotherapy was delayed. Modelling the potential impact on mortality, we found that 7,000-18,000 people with cancer were at increased risk of dying due to the pandemic. Subsequent data from ourselves and others confirmed our worst fears—all parts of the cancer pathway were affected by covid-19, while cancer research came to a standstill.  Our data contributed to the decision to restart cancer services. I’m so glad we acted quickly, sharing our data on a pre-print server before we published. These data needed to inform national policy as soon as possible. Hopefully this “real time” approach is adopted more widely to ensure rapid decision-making for the benefit of patients.
Covid-19, like cancer, does not respect national borders. We presented our data to the European Cancer Organisation (E.C.O.) Europe’s largest multi-professional cancer organization, prompting them to immediately create a Special Network on the impact of covid-19 on cancer services. Rapidly convening patient advocates and cancer experts from across Europe, we created a 7-point plan to build back better (and smarter), with a particular emphasis on using rapidly-deployed cancer intelligence, both to highlight the challenges, and to develop solutions for rapid implementation.
More recent data emphasise the scale of those challenges, with delays in endoscopic procedures, for example, precipitating a backlog of 500,000 cases, which could take over a year to clear and leading to thousands of extra deaths in patients with bowel, oesophageal, and stomach cancers in the UK.  Reducing backlogs in cancer screening, diagnosis, and treatment across Europe remains a challenge. However, getting back to pre-pandemic activity levels will not be enough; we need to be at 130% of previous capacity to limit the pandemic’s collateral damage on cancer. 
Across Europe, we’ve made great progress in cancer over the last two decades. But we must act decisively and rapidly to ensure that cancer research and care are maintained, and indeed enhanced, as we move forward. Otherwise, the progress made in the last 20 years will be reversed in less than 20 months. Cancer must never be the “Forgotten C” in the fight against covid-19.
On World Health Day, on 7 April 2021, in an initiative led by the European Cancer Patient Coalition (ECPC), we released a joint letter, signed by 292 cancer organisations across the world, calling for a global effort to mitigate the pandemic’s impact on cancer services. On 10 May, we presented new data to the European Beating Cancer Plan committee in the European parliament, highlighting the disastrous impact of covid-19 on cancer, with nearly one million “missed” cancer diagnoses in Europe due to covid-19.  On 11 May 2021, we are launching the “Time To Act” Campaign, led by E.C.O and co-created by patients and health professionals across Europe. Time To Act is an urgent solution-focussed Call to Action, emphasizing the need to take decisive steps immediately to ensure that the current covid-19 pandemic doesn’t precipitate a future cancer epidemic for the citizens of Europe.
Mark Lawler is associate Pro-Vice-Chancellor, Professor of Digital Health and Chair in Translational Cancer Genomics at Queen’s University Belfast. He is the Scientific Director of DATA-CAN, the UK’s Health Data Research Hub for Cancer and co-leads the European Cancer Organisation’s Special Network on covid-19 and Cancer and the Act Now Campaign. He is Board Member of E.C.O and a member of the Scientific Advisory Board of ECPC.
Competing interests: none further declared.
- Vrdoljak E, Sullivan R, Lawler M. Cancer and coronavirus disease 2019; how do we manage cancer optimally through a public health crisis? Eur J Cancer. 2020; 132:98-99. doi: 10.1016/j.ejca.2020.04.001. PMID: 32335477
- Lai AG, Pasea L, Banerjee A, Hall G, Denaxas S, Chang WH, Katsoulis M, Williams B, Pillay D, Noursadeghi M, Linch D, Hughes D, Forster D, Turnbull C, Fitzpatrick NK, Boyd K, Foster GR, Enver T, DATA-CAN, Cooper M, Jones M, Pritchard-Jones K, Sullivan R, Davie C, Lawler M, Hemingway H. Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency medRxiv 2020; doi.org/10.1101/2020.05.27.20083287
- Ho KMA, Banerjee A, Lawler M, Rutter MD, Lovat LB. Predicting endoscopic activity recovery in England after COVID-19: a national analysis. . Lancet Gastroenterol Hepatol. 2021 Mar 10;6(5):381-90. doi: 10.1016/S2468-1253(21)00058-3. Online ahead of print. PMID: 33713606