Delays to cancer surgery and other treatment caused by the COVID-19 crisis could result in thousands of additional deaths linked to the pandemic in England, a major study reports. New modelling has revealed the extent of the impact that disruption to the cancer care and diagnosis pathway could have on the survival of cancer patients
Many cancer patients may end up experiencing delays of several months to their cancer treatment in the context of the pandemic – including in operations to remove tumours. Those patients whose cancer will have progressed during the delay and who might otherwise have been effectively cured by surgery could now be at risk of their cancer coming back and shortening their lives.
Scientists at The Institute of Cancer Research, London, analysed existing Public Health England data on delays to cancer surgery on patients’ five-year survival rates to estimate the effect of three-month or six-month delays, respectively.
Their modelling, which factored in the risk of hospital-acquired COVID-19-infection, showed dramatic differences in the impact of delay on cancer survival depending on patients’ age, their cancer type and whether it was earlier- or later-stage cancer.
The team found that a delay of three months across all 94,912 patients who would have had surgery to remove their cancer over the course of a year would lead to an additional 4,755 deaths. Taking into account the length of time that patients are expected to live after their surgery, the delay would amount to 92,214 years of life lost.
They estimated that surgery for cancer affords on average 18.1 life years per patient, of which on average 1.0 years are lost for a three-month delay or 2.2 years are lost with a six-month delay. Considering healthcare resource more broadly, they compared this with hospital treatment for COVID-19, from which on average 5.1 life years were currently gained per patient.
Study leader Professor Clare Turnbull, professor of cancer genomics at the ICR, said: “The COVID-19 crisis has put enormous pressure on the NHS at every stage of the cancer pathway, from diagnosis right across to surgery and other forms of treatment. Our study shows the impact that delay to cancer treatment will have on patients, with England, and the UK more widely, potentially set for many thousands of attributable cancer deaths as a result of the pandemic.
“Our findings should help policymakers and clinicians make evidence-based decisions as we continue to deal with the effects of the pandemic on other areas of medicine. We have to ensure that both patients with COVID-19 and also those with cancer get the best possible care. That means finding ways for the NHS to get back to normal service on cancer diagnostics and surgery as soon as possible, prioritising certain cancer types in particular.”
Professor Paul Workman, CEO of the ICR, said: “The COVID-19 pandemic has already devastated the lives of many people directly. Now, these new findings show the potential for the pandemic to also have a terrible indirect impact on the lives of cancer patients.
“It’s positive that the NHS is now beginning to adapt to the new normal, and to think about how cancer services such as surgery can be restored as soon as possible. I also strongly welcome moves to treat patients with targeted cancer drugs, or shorter, more intense courses of radiotherapy, as ways of preserving survival rates while minimising the time they have to spend in hospital.”
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.
Amit Sud, Michael Jones, John Broggio, Chey Loveday, Bethany Torr, Alice Garrett, David L Nicol, Shaman Jhanji, Stephen A Boyce, Firza Gronthoud, Phillip Ward, Jonathan M Handy, Nadia Yousaf, James Larkin, Yae-Eun Suh, Stephen Scott, Paul DP Pharoah, Charles Swanton, Christopher Abbosh, Matthew Williams, Georgios Lyratzopoulos, Richard Houlston, Clare Turnbull