The COVID-19 pandemic has bought great challenges to healthcare systems globally. A World Health Organization (WHO) survey of 155 countries in the height of the pandemic reported disrupted services worldwide, ranging from the treatment of cardiovascular emergencies, to rehabilitation programmes and the management of diabetes . Cancer services have also been largely disrupted by the COVID-19 pandemic; almost every aspect of cancer care has been affected, including clinical research, diagnosis and delivery of treatment, all of which are likely to have long-lasting ripple effects .
The NHS offers bowel, breast and cervical cancer screening programmes to identify individuals at high risk of these cancers and to enable early diagnosis and treatment for those affected . In the height of the pandemic, cancer screening services were paused across the UK, both to protect individuals from COVID-19 infection and to enable the redeployment of healthcare professionals to support in critical areas . During this time, it has been predicted that approximately 200,000 people per week across the UK were not screened for cancer, equating to over 2,200 possible missed cancer cases and resulting in waiting lists for screening appointments continuing to grow [5, 6].
Concerns have been raised over the economical and psychological implications of delayed screening, both of which are expected to increase. These are important factors to consider, as early cancer detection and diagnosis saves money for the NHS and early treatment initiation has been found to improve patients’ quality of life .
Investigations and diagnosis
As expected, patients have been reluctant to attend appointments with their general practitioner (GP) during the pandemic. This, along with concerns from some GPs about referring patients to hospital, caused the number of urgent referrals to drop by around 25% in England during the early months of the pandemic . For patients who were referred but required non-urgent diagnostic investigations, this often resulted in deferred appointments because only 2-week-wait urgent referrals were eligible for further investigations.
The implementation of remote GP consultations (via telephone or video) could also have played a role in the decreased number of urgent referrals for cancer screenings. Remote consultations mean that doctors do not have the opportunity to physically examine their patients, leading to missed signs and symptoms that would usually warrant referral; therefore, missed cancer diagnoses are likely to have increased during this time .
Patients with cancer, particularly those receiving chemotherapy, radiotherapy and/or immunotherapy, are at an increased risk of the symptoms and long-term effects of COVID-19 compared with their healthy counterparts. Therefore, decisions regarding the treatment of such individuals have necessitated a thorough assessment to weigh up the benefits of commencing or continuing treatment against the risk of a possible COVID-19 infection to patient health . In England, there was a 37% drop in the number of patients commencing cancer treatment in May 2020 compared with the same period in 2019 .
Current NICE guidance states that face-to-face contact should continue to be minimised by opting for telephone or video consultations, postponing non-essential follow-up appointments, using home delivery of medicines, using drive-through medication collection and utilising local services for blood tests . NICE has also issued guidance for prioritising systemic anticancer treatments, with the highest priority being given to those with over a 50% chance of curative success .
Looking to the future
Although there is a large backlog of delayed appointments, many cancer screening programmes have recently recommenced their services across the UK. Important measures have been implemented to ensure that appointments are COVID-19 safe, such as providing personal protective equipment (PPE) for staff, requiring patients to wear a mask and performing temperature checks upon patients’ arrival at the clinic [4, 12]. However, with COVID-19 cases rising, it is unknown if screening appointments will be paused once again for the safety of patients and to compensate for the increased demand that the pandemic puts on the NHS .
Since the number of urgent cancer referrals hit their lowest point in April, the numbers of cancer referrals and individuals starting cancer treatment have slowly increased but, unfortunately, these figures are still lower than pre-lockdown levels . However, with updated government guidelines being issued regularly in response to the number of COVID-19 cases, it is possible this could soon change .
Over the course of the pandemic so far, it is clear that there has been a change in health-seeking behaviour. It is unknown if, and for how long, this change in behaviour will continue and how much of an impact this will have on the diagnosis and management of cancer in the future . With the outlook uncertain, and a second wave of COVID-19 cases under way, it is evident that cancer services will need to continue to adapt their usual practices to ensure that the diagnosis and management of patients with cancer is performed in a safe and timely manner .
- World Health Organization. COVID-19 significantly impacts health services for noncommunicable diseases. Available at: https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases. Accessed October 2020.
- Medical Xpress. Study offers global review of impact of COVID-19 on cancer treatment and research. Available at: https://medicalxpress.com/news/2020-10-global-impact-covid-cancer-treatment.html. Accessed October 2020.
- National Health Service. NHS screening. Available at: https://www.nhs.uk/conditions/nhs-screening/. Accessed October 2020.
- Cancer Research UK. Cancer screening and coronavirus (COVID-19). Available at: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/coronavirus/cancer-screening. Accessed October 2020.
- Cancer Research UK. How coronavirus is impacting cancer services in the UK. Available at: https://scienceblog.cancerresearchuk.org/2020/04/21/how-coronavirus-is-impacting-cancer-services-in-the-uk/. Accessed October 2020.
- Tan KK and Lau J. Cessation of cancer screening: An unseen cost to the COVID-19 pandemic? Eur J Surg Oncol 2020; Epub ahead of print (DOI: 10.1016/j.ejso.2020.05.004).
- Maringe C, Spicer J, Morris M 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. Lancet Oncol 2020; 21 (8): 1023–1034.
- Jones D, Neal RD, Duffy SRG et al. Impact of the COVID-19 pandemic on the symptomatic diagnosis of cancer: The view from primary care. Lancet Oncol 2020; 21 (6): 748–750.
- Cancer Research UK. What’s happened to cancer services during the COVID-19 pandemic? Available at: https://scienceblog.cancerresearchuk.org/2020/09/11/whats-happened-to-cancer-services-during-the-covid-19-pandemic/. Accessed October 2020.
- National Institute for Health and Care Excellence. COVID-19 rapid guideline: Delivery of systemic anticancer treatments; Communicating with patients. NICE guideline (NG161); March 2020. Available at: https://www.nice.org.uk/guidance/ng161/chapter/1-Communicating-with-patients. Accessed October 2020.
- National Institute for Health and Care Excellence. COVID-19 rapid guideline: Delivery of systemic anticancer treatments; Prioritising systemic anticancer treatments. NICE guideline (NG161); March 2020. Available at: https://www.nice.org.uk/guidance/ng161/chapter/6-Prioritising-systemic-anticancer-treatments. Accessed October 2020.
- Cancer Research UK. Going into hospital during the coronavirus pandemic. Available at: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/coronavirus/going-into-hospital. Accessed October 2020.
- BBC News. COVID-19 in the UK: How many coronavirus cases are there in your area? Available at: https://www.bbc.co.uk/news/uk-51768274. Accessed October 2020.
- UK. Coronavirus (COVID-19). Available at: https://www.gov.uk/coronavirus. Accessed October 2020.
Author: Jessica Sale, Porterhouse Medical Group, Associate Medical Writer and Medical Advisory Group member.