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The Covid effect: clearing the cancer backlog

As exhausted NHS staff struggle to reduce a backlog of cancer cases caused by the coronavirus pandemic, the government is facing calls for a radical rethink of services

In a hospital room, an asian female cancer patient is chatting with her doctor. Both of them are wearing a mask during the coronavirus pandemic to help prevent the transfer of germs. The doctor is a female and of African American ethnicity.

In cancer treatment, early diagnosis saves lives. As we recover from the coronavirus outbreak, pandemic-driven delays look set to result in thousands of additional deaths. 

The true number of cancer casualties due to Covid-19 will only become clear in the coming years, but one estimate by University College London and DATA-CAN: The Health Data Research Hub for Cancer puts the additional UK cancer death toll at as high as 18,000 over the next 12 months.

Data from DATA-CAN also shows that during the first wave of the pandemic in 2020, 70% of people with suspicious symptoms were not referred to specialist cancer services, while 40% of chemotherapy treatments were delayed.

The Department of Health and Social Care (DHSC) says cancer diagnosis and treatment has remained a top priority throughout the pandemic. The majority of patients referred by a GP see a cancer specialist within two weeks, DHSC claims, while more than 2 million urgent referrals have taken place and 570,000 people have been receiving treatment since the pandemic began.

We hope the pandemic will prompt reconfiguration of cancer services to better protect future delivery in the face of the next crisis

In March 2021, urgent referrals by a GP for cancer were the highest recorded since cancer data collection began, with an average of more than 10,000 patients referred each working day. That is more than 232,000 referrals in total, up by 26.4% compared to the previous March.

But according to Cancer Research UK (CRUK), an estimated 3 million fewer people were screened for cancer between March and September last year. As a result, that means around 9,200 fewer patients started treatment in England alone, and 45,000 fewer cancer patients were diagnosed or treated between March 2020 and March 2021.

Another way of measuring the impact of Covid is that there were 330,000 fewer GP urgent referrals between March 2020 and March 2021, 13% down on the previous 12 months, creating a backlog that over-stretched staff are now trying to deal with.

The impact on survival rates

“The impact on cancer of the pandemic has clearly been devastating,” says Kruti Shrotri, head of policy development at CRUK. “We fear cancer survival rates will decline for the first time. There are lots of people out there who have cancer but don’t know it.”

Clare Turnbull, professor of translational cancer genetics at London’s Institute of Cancer Research, says people who have been scared to visit their GP or go to the hospital for fear of catching Covid are presenting later with worse symptoms and more advanced cancer that may be more difficult to treat. 

“We can expect the resulting delays to diagnosis and treatment will lead to substantial avoidable deaths across different cancer types in coming years,” she says. Any significant delay in presentation, diagnosis or treatment could make a critical difference, she says, meaning the patient misses the window for their cancer to be picked up and treated while it can be cured and they have a normal life expectancy. 

“The danger is if you pass through that window then your cancer turns out to have progressed and is no longer curable.”

Initial modelling early in the pandemic demonstrated that if each patient across 20 common cancer types referred along the urgent referral pathway experienced a total delay to treatment of one month compared to previous years, this would result in 1,400 lives lost a year and 25,800 life-years lost. A six-month delay would result in 9,300 lives and 173,500 life-years lost, says Turnbull. 

The delay experienced by each patient with a potentially curable cancer is difficult to determine as it’s a combination of their delay in getting a GP appointment, delay in referral, delay in hospital diagnostic tests, delay in additional and often complex imaging studies to discover the extent or stage of the cancer, delay in surgery and delay in any chemotherapy or radiotherapy accompanying the surgery. 

The issue of late-stage diagnosis

“Data is coming through showing, as predicted, an upwards shift in the stage at which cancers have been diagnosed over the past 14 months. We know this will equate to more deaths,” says Turnbull.

She acknowledges NHS staff have worked tirelessly to reinstate cancer services as rapidly as possible. However, there is still a major backlog of patients awaiting outpatient appointments, investigations and surgeries.

There have been approximately 40,000 fewer cancer diagnoses over the last 14 months, Turnbull says, so during the coming months the NHS is likely to be dealing with more cancer presentations than normal, while also working at 80% of its usual capacity due to social distancing and other infection-control measures. 

“Covid-19 has caused an acute-on-chronic crisis in cancer care. During the rise of the pandemic in spring 2020, unprecedented pressure on hospital beds and intensive care units, redeployment of staff, caution regarding transmission in hospitals, reduced primary care access and population lockdown combined in a perfect storm, dramatically disrupting UK cancer care pathways,” Turnbull says.

“However, the pandemic arose against a backdrop of cancer outcomes already deteriorating compared to countries in the Organisation of Economic Co-operation and Development. This decline is due to chronic, worsening capacity issues, mainly relating to shortages in cancer professionals, from nurses, doctors and surgeons to radiographers, clinical scientists and pathologists.”

There’s never a good time to have cancer, but the pandemic is a bad time

Lung and prostate cancers in particular are going undiagnosed, says Shrotri. “A cough may be a sign of Covid, but it could also be lung cancer,” she says. Breast cancer treatment has also been impacted as screening programmes were paused, so many cases of breast cancer went undiagnosed.

The UK has three cancer screening programmes for breast, bowel and cervical cancer. Because of Covid, invitations and follow-up appointments have been delayed.

But cancer surgery has been hardest hit. “We saw a 40% drop in surgery, mainly because of the need to prioritise intensive care beds for Covid patients,” says Shrotri. “There’s never a good time to have cancer, but the pandemic is a bad time. Many patients thought they were forgotten.”

It has been “devastating to see diagnosis and treatment paused and delayed”, Shrotri continued, with some patients dying or curative treatment now coming too late. 

“Over the past couple of months, more people than usual are coming through the system, so the NHS is starting to tackle the backlog, but there’s a very long way to go. We’re still not seeing as many people as we would expect.”

Building back smarter

Mark Lawler, professor of digital health at Queen’s University Belfast and scientific lead at DATA-CAN, says the data suggests cancer services now need to be operating at 130% of pre-Covid levels.

“Getting back to 100% is not enough,” he says. “It’s soul destroying when you see the numbers and every one of those numbers represents a person.”

While the pandemic has shown that our cancer services are not as resilient as we thought, “this is a huge opportunity to reimagine cancer services and build back smarter using data with an innovative approach”, he adds. 

Lawler, who is also co-chair of the European Cancer Organisation’s Special Network on Covid-19 and Cancer, says the pandemic backlog calls for a pan-European approach.

The organisation’s seven-point plan aims to address that backlog by restoring confidence in cancer health services; tackling medicines, products and equipment shortages; filling gaps in the cancer workforce; employing innovative technologies and solutions to strengthen cancer systems and provide optimal care for patients; embedding data collection and rapid deployment of cancer intelligence to enhance policy delivery; and securing and sustaining deeper long-term European health co-operation.

“It’s very much a pan-European plan rather than a European Union plan; cancer knows no borders,” says Lawler.

Turnbull at the Institute of Cancer Research adds: “It is a grave mistake to believe these issues can all be solved by a year or two’s extra funding for ‘Covid recovery’. We desperately require a long-term cross-party plan for cancer care to allow us to turn around the downward trajectory of our cancer outcomes. Only then can we ensure we have cancer services we can be proud of on a normal day, but which are resilient to future disruptors, be it seasonal flu or the next pandemic.”

Levelling up inequalities

Professor Charles Swanton, chief clinician for CRUK, says that building back should also mean levelling up, addressing “longstanding, unacceptable cancer inequalities” across the UK that every year equate to around 20,000 more cancer cases.

“There have been huge breakthroughs in the last decade in life-saving cancer research, for example in cancer immunotherapy, but we need the breakthroughs of tomorrow,” he says.

Investment is needed on multiple levels: workforce, equipment, primary care, rapid diagnostic centres and the clinical research scientists who will help deliver medical breakthroughs. 

“If the right approach is taken, the UK can emerge from this pandemic with a cancer pathway that is more innovative, flexible and better equipped to save more lives,” says Swanton.

We have learnt much from our lack of readiness for the Covid-19 pandemic, says Turnbull. A key element of future pandemic planning will be predefined protocols and processes to ensure the safety of staff and cancer patients from infection, along with rational prioritisation for delivering medical procedures. 

“Cancer pathways are complex and thus fragile; we need to ensure they remain resilient to future extrinsic disruption,” according to Turnbull. “Countries around the world and elsewhere in Europe have shown standalone facilities can help to maintain cancer services alongside overburdened hospitals. We hope the pandemic will prompt reconfiguration of cancer services to better protect future delivery in the face of the next crisis.”

The DHSC says: “The NHS has published its plan to recover cancer services, and we’re providing an extra £1 billion to boost diagnosis and elective treatment in the year ahead as well as investing £325 million in NHS diagnostic machines to improve the experience of cancer patients.”

This is a huge opportunity to reimagine cancer services and build back smarter

The government response is headed by Professor Peter Johnson, national clinical director for cancer, who heads the Cancer Recovery Taskforce, which reports to the National Cancer Board. The board oversees delivery of the NHS Long Term Plan’s ambitions to diagnose 75% of cancers at stage 1 or 2 and for 55,000 more people to survive cancer for five years or more by 2028.

NHS priorities and operational planning guidance from March 2021 sets out targets to return to 85% of 2019-20 levels by July 2021 for elective treatments and for this to rise in the autumn. The aim is also to meet the increased level of referrals and treatment required to address the shortfall in the number of first treatments by March 2022.

Cancer care threatened by staff burnout

The NHS faces a worsening staffing crisis as doctors, nurses and other healthcare professionals are inundated with record numbers of cancer patients whose diagnosis has been delayed by the pandemic.

Dealing with the delayed referrals, diagnosis and treatment will mean “squeezing more out of exhausted NHS staff”, says Clare Turnbull, professor of translational cancer genetics at the Institute of Cancer Research. “Theatre staff, who already work many weekends, are being asked to come in on extra Saturdays and Sundays to perform catch-up theatre lists.”

There is growing concern about staff burnout and fears that the pandemic may precipitate a wave of departures or early retirement of healthcare workers. In combination with Brexit and greater barriers to immigration, the NHS may find workforce shortages worsening just when it needs to deliver increased levels of cancer services.

It takes five to 10 years to train a nurse and 10 to 15 years to train a doctor, Turnbull notes; expanding training places now for medical, nursing and other healthcare professionals will only deliver more staff in a decade or so. 

“We cannot continue to procrastinate, nor seemingly can we be so confident in our existing model of acquiring overseas-trained clinical staff from other stretched healthcare services.”

Kruti Shrotri, head of policy development at Cancer Research UK, says CRUK has been calling on the government to invest in more NHS staff for many years. “Now it’s a top priority for the coming Spending Review,” she says. “The increase in capacity needed is going to be substantial.”

However, investment in staff will take time to come through, she says – the NHS needs to step up to the challenge now. 

“There need to be more innovative ways of dealing with the backlog.”

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