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      The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study

      research-article

      , PhD a , , Prof, PhD c , e , , PhD b , , Prof, MD c , e , , Prof, PhD b , , Prof, PhD c , d , e , , Prof, PhD a , , , PhD b , d , e , * ,

      The Lancet. Oncology

      Lancet Pub. Group

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          Summary

          Background

          Since a national lockdown was introduced across the UK in March, 2020, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred, and only urgent symptomatic cases prioritised for diagnostic intervention. In this study, we estimated the impact of delays in diagnosis on cancer survival outcomes in four major tumour types.

          Methods

          In this national population-based modelling study, we used linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15–84 years, diagnosed with breast, colorectal, and oesophageal cancer between Jan 1, 2010, and Dec 31, 2010, with follow-up data until Dec 31, 2014, and diagnosed with lung cancer between Jan 1, 2012, and Dec 31, 2012, with follow-up data until Dec 31, 2015. We use a routes-to-diagnosis framework to estimate the impact of diagnostic delays over a 12-month period from the commencement of physical distancing measures, on March 16, 2020, up to 1, 3, and 5 years after diagnosis. To model the subsequent impact of diagnostic delays on survival, we reallocated patients who were on screening and routine referral pathways to urgent and emergency pathways that are associated with more advanced stage of disease at diagnosis. We considered three reallocation scenarios representing the best to worst case scenarios and reflect actual changes in the diagnostic pathway being seen in the NHS, as of March 16, 2020, and estimated the impact on net survival at 1, 3, and 5 years after diagnosis to calculate the additional deaths that can be attributed to cancer, and the total years of life lost (YLLs) compared with pre-pandemic data.

          Findings

          We collected data for 32 583 patients with breast cancer, 24 975 with colorectal cancer, 6744 with oesophageal cancer, and 29 305 with lung cancer. Across the three different scenarios, compared with pre-pandemic figures, we estimate a 7·9–9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis, corresponding to between 281 (95% CI 266–295) and 344 (329–358) additional deaths. For colorectal cancer, we estimate 1445 (1392–1591) to 1563 (1534–1592) additional deaths, a 15·3–16·6% increase; for lung cancer, 1235 (1220–1254) to 1372 (1343–1401) additional deaths, a 4·8–5·3% increase; and for oesophageal cancer, 330 (324–335) to 342 (336–348) additional deaths, 5·8–6·0% increase up to 5 years after diagnosis. For these four tumour types, these data correspond with 3291–3621 additional deaths across the scenarios within 5 years. The total additional YLLs across these cancers is estimated to be 59 204–63 229 years.

          Interpretation

          Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer.

          Funding

          UK Research and Innovation Economic and Social Research Council.

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          Most cited references 17

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          Collateral damage: the impact on outcomes from cancer surgery of the COVID-19 pandemic

          Background Cancer diagnostics and surgery have been disrupted by the response of healthcare services to the COVID-19 pandemic. Progression of cancers during delay will impact on patient long-term survival. Methods We generated per-day hazard ratios of cancer progression from observational studies and applied these to age-specific, stage-specific cancer survival for England 2013-2017. We modelled per-patient delay of three months and six months and periods of disruption of one year and two years. Using healthcare resource costing, we contextualise attributable lives saved and life-years gained from cancer surgery to equivalent volumes of COVID-19 hospitalisations. Findings Per year, 94,912 resections for major cancers result in 80,406 long-term survivors and 1,717,051 life years gained. Per-patient delay of three/six months would cause attributable death of 4,755/10,760 of these individuals with loss of 92,214/208,275 life-years. For cancer surgery, average life-years gained (LYGs) per patient are 18.1 under standard conditions and 17.1/15.9 with a delay of three/six months (an average loss of 0.97/2.19 LYG per patient). Taking into account units of healthcare resource (HCRU), surgery results on average per patient in 2.25 resource-adjusted life-years gained (RALYGs) under standard conditions and 2.12/1.97 RALYGs following delay of three/six months. For 94,912 hospital COVID-19 admissions, there are 482,022 LYGs requiring of 1,052,949 HCRUs. Hospitalisation of community-acquired COVID-19 patients yields on average per patient 5.08 LYG and 0.46 RALYGs. Interpretation Modest delays in surgery for cancer incur significant impact on survival. Delay of three/six months in surgery for incident cancers would mitigate 19%/43% of life-years gained by hospitalisation of an equivalent volume of admissions for community-acquired COVID-19. This rises to 26%/59% when considering resource-adjusted life-years gained. To avoid a downstream public health crisis of avoidable cancer deaths, cancer diagnostic and surgical pathways must be maintained at normal throughput, with rapid attention to any backlog already accrued.
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            The relative survival rate: a statistical methodology.

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              The impact of the COVID-19 pandemic on cancer care

              The COVID-19 pandemic has disrupted the spectrum of cancer care, including delaying diagnoses and treatment and halting clinical trials. In response, healthcare systems are rapidly reorganizing cancer services to ensure that patients continue to receive essential care while minimizing exposure to SARS-CoV-2 infection.
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                Author and article information

                Contributors
                Journal
                Lancet Oncol
                Lancet Oncol
                The Lancet. Oncology
                Lancet Pub. Group
                1470-2045
                1474-5488
                1 August 2020
                August 2020
                : 21
                : 8
                : 1023-1034
                Affiliations
                [a ]Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
                [b ]Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
                [c ]School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
                [d ]Institute of Cancer Policy, King's College London, London, UK
                [e ]Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
                Author notes
                [* ]Correspondence to: Dr Ajay Aggarwal, Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK ajay.aggarwal@ 123456lshtm.ac.uk
                [†]

                Joint senior authors

                Article
                S1470-2045(20)30388-0
                10.1016/S1470-2045(20)30388-0
                7417808
                32702310
                cdaaf25d-295d-4e85-802c-4b7f5be8045a
                © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                Categories
                Article

                Oncology & Radiotherapy

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