Cancer services during COVID-19: 40,000 fewer people starting treatment

There's been a steady stream of figures since the pandemic began.

The number of COVID-19 cases. The number of hospitalisations. The number of people waiting for screening, tests or treatment. The number of cancer surgeries that have been postponed or canceled.

Each figure lays bare what many people with cancer have seen first-hand—the devastating impact COVID-19 has had on people with cancer, health service capacity and the efforts to recover.

"Health services across the UK worked hard to try to get services functioning normally throughout the pandemic, and especially when the number of COVID-19 cases fell—a monumental task that could not have been achieved without the hard work and dedication of the staff," says Jon Shelton, a senior cancer intelligence manager at Cancer Research UK.

But the sustained disruption the pandemic caused throughout 2020 has left a deep rift in cancer care, with 40,000 fewer people starting cancer treatment across the UK last year.

While this figure looks specifically at treatment, it's largely driven by a drop in the number of people who were diagnosed with cancer in 2020. And it's worrying, as Shelton explains.

"The number of people diagnosed with cancer or starting treatment in the UK each year is usually relatively predictable. We don't see large changes within a cancer site year on year unless a big change is introduced, like a new screening program." Shelton says there can be fluctuations—for example there was an unusually large increase of about 10,000 prostate cases in 2018 following the high-profile prostate cancer diagnoses of Stephen Fry and Bill Turnbull, but we are usually confident of estimating the overall figure to within a few thousand each year. "So a drop of 40,000 is big."

So, where are the 40,000 people who would have expected to start cancer treatment, but haven't? The majority will be in the community, living with cancer without knowing about it, and with the potential that their tumor could grow and spread, they really need to be diagnosed and treated as soon as possible.

Which could pose a challenge for health services.

"How do health services, which were struggling to cope before the pandemic, now cope with this influx of people. Because most of those 40,000 still need to come through on top of the people who would normally be diagnosed in 2021."

Cancer diagnosis
We've written before about the impact of COVID-19 on cancer diagnosis early on in the pandemic.

The number of people going to their GP after noticing a change in their body at the beginning of the first lockdown fell dramatically.

After plummeting at the beginning of the pandemic, urgent suspected cancer referrals were rising through the year, hitting pre-COVID-19 levels in England and Wales by Autumn. But there was still work to be done, as recovery was not the same across the board. Numbers of urgent referrals for suspected lung cancer are still the most impacted across the nations, followed by suspected urological cancers—such as prostate and kidney cancer.

Urgent suspected cancer referrals are only one part of the picture, with normally around two in five people with cancer being diagnosed through this route. But they're a good indication of how many people are coming forward with symptoms and how cancer services are doing across the UK, alongside figures looking at the tests used to diagnose cancer when someone is referred.

Most of the diagnostic test figures aren't specific to cancer. But monitoring the tests that are often used to diagnose cancer—endoscopies, CT scans, non-obstetric ultrasounds and MRI—can give a picture of how cancer services are running and how many people are being referred into secondary care.

Again, it's a mixed picture. Endoscopy services have been particularly impacted by the pandemic, with around 600,000 fewer endoscopies performed in England between March and November and the number of endoscopies performed in November still not back to pre-pandemic levels.

And the longer they take to recover, the bigger the backlog gets. The number of patients waiting for an endoscopy hit 200,000 in November 2020 in England, up 49% compared with the previous year. A similar picture can be seen in Northern Ireland, Wales and Scotland, with 12,000 more people in Scotland on the endoscopy waiting list in September compared to the previous year.

And that's before the second wave of COVID-19 reached its peak in the UK. The most recent data takes us to November, when restrictions in UK nations began to tighten as COVID-19 cases rose. Since then, the pressure on health services has only increased. The worry is that this could lead to the endoscopy waiting list growing even further.

"There's a concern around waiting lists for endoscopies and what the delays could mean for the patients that do have cancer and the growth of their tumor. There's a lot of interest in using tests, such as the Fecal Immunochemical Test (FIT) to help establish which patients need seeing most urgently. But not everyone with cancer has a positive FIT result, so it's important to remain vigilant to the risk of cancer and get those on the waiting lists seen as quickly as possible. "

Health services are open

Jodie Moffat, Cancer Research UK's head of early diagnosis said that with the return of the 'protect the NHS' message, it's important for people who notice any changes in their health to know that health services are still open.

"During the first wave, many people didn't seek help because they didn't want to add to GPs' workloads, but it's vital people don't delay contacting their GP if they notice anything that's unusual for them or isn't going away. In most cases it won't be cancer, but it's best to get it checked out. We've heard reports of people struggling to get through to their GP practice or to secure an appointment which can be frustrating, but please do keep trying."

Impact on cancer treatment

When it comes to cancer treatment, we've got less timely data . But the biggest disruption has been on cancer surgery. This was true at the start of the pandemic and it's true of the last few weeks.

Stories in recent weeks suggest that the greatest impact has been felt in hospitals in London and the East of England, but the strain of the pandemic is being felt right across the UK.

Cancer surgery has been the most heavily impacted for a number of reasons, a big one being intensive care capacity. "For certain cancer operations, you can't start the surgery unless there's a bed in intensive care guaranteed to be available," says Shelton. "So those major surgeries may be delayed in hospitals that are running low on capacity due to the number of COVID-19 cases."

The other big thing is staff numbers. "Surgery involves a sizeable team. It's not just the surgeon, it's nurses, anesthetists and support staff. And if staff numbers are low because people are off with COVID-19, are self-isolating or because they've been redeployed to a COVID-19 ward, that makes it difficult."

Other cancer treatments—radiotherapy or chemotherapy for example—don't require as many staff to deliver. And on the whole, these services have kept running throughout the second wave.

Governments and health service leaders have been making plans to ensure vital cancer surgeries go ahead. In England, NHS England has told hospitals to give cancer the same priority as coronavirus. Health services are also looking to the independent sector for additional capacity. Scotland have announced a partnership with a handful of independent hospitals in Scotland, which will help for some operations. And a similar arrangement has been made in England, with NHS England telling hospital trusts to use up to 100% of independent hospital capacity where required.

As well as ensuring that vital cancer services can continue, an additional benefit of using independent hospitals is that they don't have A&E or critical care units, helping to limit the spread of COVID-19 within hospitals. But without critical care, the type of operations that can be carried out are also limited.

"It will mainly be surgeries where the chance of needing intensive care is minimal," says Shelton. "A lot of breast and prostate cancer surgeries will fall into this category. Whereas a more invasive surgery that involves opening up the chest to get to the lungs or brain surgery will need to be carried out where there's intensive care available."

Another concern is that independent hospitals aren't evenly distributed throughout the country, with a high concentration of hospitals located in the South of England, which could lead to inequality in service.

Another option being used by many cancer specialists is to offer people an alternative treatment option—radiotherapy before surgery or instead of chemotherapy for example.

A study by Professor Eva Morris at Oxford University has shown the impact of COVID-19 on cancer care for people with bowel cancer. This not only confirmed the large drop in the number of bowel cancer patients receiving surgery from April 2020 but also showed that a lower proportion of people received the less invasive laparoscopic surgery which is better for the patient's recovery. For rectal cancer, a type of bowel cancer, there was also a large increase in the use of radiotherapy before surgery, so the treatments that patients are receiving have changed as a result of COVID-19.

But while these decisions were made in the best interests of patients, normal service must resume as soon as possible. "For solid tumors, surgery is often the best shot at curing someone's cancer, so it's imperative that patients receive this treatment when it's best for them."

Building better cancer services

Ten months on from the start of the pandemic in the UK, the picture is still changing day by day. But things have moved on—the COVID-19 vaccination program has begun, with over 10% of the UK having received at least one dose of the vaccine. Cases of COVID-19 and hospitalisations are also falling.

Last year's figures also show that recovery of cancer services is possible, thanks to the dedication of healthcare staff and the work of healthcare planners in all four UK nations. But there's still a lot more to do.

Because now is the time to not only rebuild our cancer services, but to make them world-class.

Governments across the UK have bold ambitions to improve cancer survival for the one in two of us who will be diagnosed with the disease. We must return, as soon as possible, to driving faster and earlier diagnosis of cancer at an early stage when chances of survival are greatest—so that everyone gets the cancer care they deserve.