How did this crisis in the UK unfold?
At the start of the first lockdown the public health messaging was clear. Stay at home, save lives, protect the NHS. Cancer screening was suspended, routine referrals for diagnostic investigation deferred or cancelled and large declines in the 2-week wait (ww) urgent referrals for diagnostic workup of suspected cancers were almost immediately evident.13 For example, in England, between March and November 2020, there were 18 000 fewer referrals for suspected lung cancer (down to 35% of prelockdown referrals).7 14 Fewer diagnostic investigations were also seen across all types of cancer.7 9 15 16
The impact of such profound changes to patterns of patient presentation as well as delays in the diagnostic and treatment pathway, was considered in four major modelling studies published within 3 months of the first lockdown.4 17–19 It was estimated that 60 000 years of life would be lost for only four cancers assuming disruption of diagnostic services for 3 months with no further pandemic waves and complete recovery of diagnostic services.4 These figures are conservative as the complete recovery of diagnostic and treatment services has not materialised, they do not consider the effect of any treatment delay, nor specifically the impact of delay in stage IV disease, which resulted in some patients not receiving any treatment. However, there is an urgent need to deliver these analyses based on observed data in order to be in a position to understand exactly how different the situation is from that predicted, and to also learn from the pandemic experience.
Once diagnosed, treatment delays became a major concern as surgical activity nearly ground to a halt in many centres for the first few weeks,20 despite attempts to establish COVID-19-free or ‘cold’ sites.21 22 Part of the reluctance to perform surgery was based on data suggesting that rates of peri-operative mortality were significantly higher23—claims that were disproven when considering elective care.20 In addition, there were concerns that patients with cancer in general were likely to be more vulnerable. However, the initial evidence was flawed with limited evaluation of other case mix criteria.24 25
In the early stages of the pandemic, national guidance was also being released by professional bodies in an attempt to support safe delay of some cancer surgeries including colorectal and oesophageal cancer for up to 12 weeks.26 In response to this, Hanna et al3 rapidly published a systematic review and meta-analysis in September 2020, which showed there was no evidence for assuming that there was any ‘safe’ period of delay for cancer care. They found that across all three major treatment modalities that a treatment delay of 4 weeks is associated with an increase in the risk of death. For example for breast surgery there is a 6%–8% increase in death for every 4-week delay and a 12-week delay would increase the risk by 26%. While the included studies are likely to be at risk of unobserved confounding, these findings do question who was responsible for rapid appraisal and evidence reviews during the pandemic that were necessary to support and implement best practice.
Conversely the radiotherapy community aided by randomised control trial evidence were able to adopt guidelines supporting shorter and equally effective radiotherapy regimens.27 This made a significant difference to preserving capacity and minimising hospital attendances for breast cancer and a range of other tumour types.28 Radiotherapy was also used as a substitute for bladder and oesophageal cancer surgery.29 The omission of systemic agents with some radiation regimens, instituted to improve safety is, however, expected to diminish their efficacy.30
With respect to systemic therapy, strategies tended to be built around the precautionary principle, with first-line treatment in metastatic disease and curative/adjuvant treatments taking priority.31 Interim guidance and funding also supported utilisation of regimens associated with lower toxicity and reduced frequency of administration, although it is not clear for some regimens whether there is likely to be a reduction in treatment efficacy overall.32 Broadly though the NHS was able to maintain systemic therapy services33 during this period with no evidence for increased mortality for those undergoing chemotherapy or immunotherapy infected with COVID-19.34
By December 2020, NHS England had set out their recovery plan for cancer services, which prioritised the NHS long-term plan commitments such as the use of rapid diagnostic centres, targeted lung health checks and bowel screening.35 Engagement work with charities sought to encourage patients to come forward and specific guidance was provided to NHS Trusts to ensure patients with particularly long waits were tracked particularly those from low socioeconomic groups. The increased use of faecal immunochemical testing for colorectal screening was strongly supported.
The NHS in the early stages of the pandemic ringfenced private sector capacity including staff and theatre space to be used for the most urgent NHS cases. However, utilisation of private sector capacity was inefficient,36 with a 43% reduction in NHS activity within the private sector compared with the year before, despite the government contributing up to 100% of the operating costs as part of the partnership. The deal ended in August 2020; the point at which this additional capacity could have been used to start to address the backlog.
After August 2020, negotiations with the private sector for use of their capacity was expected to be undertaken at a regional level but was inequitably implemented. For example in London, patients had NHS cancer pathway operations cancelled yet the same NHS surgeons were able to operate in the private sector for those who could afford to pay.37 The two tier system the NHS has fought so hard to avoid, developed at pace during the pandemic and continues even during the present recovery period as the backlogs lengthen.
As predicted earlier on in the pandemic, excess deaths from non communicable disease are on the rise. Since April 2022, there have been 22 500 more deaths than expected, the majority unrelated to COVID-19.38 39 We must reflect whether we could have done anything different and whether cancer services—the single largest cause of death in the UK40—were adequately prioritised?
At the start of the pandemic, the focus was on managing and prioritising patients under conditions of great uncertainty, which meant deployment of services towards acute care. However, there was a failure to provide public health messaging that conveyed accurately the magnitude of risks of severe illness from SARS-CoV-2 infection compared with the risks of not seeking healthcare-advice if symptomatic from cancer or other conditions. In addition, clinicians needed information to support and manage the risks of undertaking diagnostic and surgical procedures during the pandemic and which patients were at higher risks of COVID-19-related death or indeed which procedures conferred greater risks to themselves. Any undue risk aversion could result in considerable delays for patients and it was not until December 2020 when the first models were available.41
In July 2020, the UK Office for National Statistics (ONS) published their estimates of the indirect impacts of the pandemic on other health conditions.42 They estimated that the indirect effects of the pandemic and non-pharmaceutical interventions, during the first 6 months, would result in the loss of 1400 lives and 3500 quality-adjusted life-years (QALYs) across eighteen cancers over 5 years. The ONS figures were a woeful underestimate and likely to have been used to justify prioritisation of resources (including staff) and the framing of public health messaging. Of concern is that the methods used, particularly the conceptual framework lacks the requisite detail to enable robust review. Furthermore, the relationship between excess deaths and years of life lost do not align with other studies4 with the ONS analysis weighting years of life lost per COVID-19 death considerably higher than for cancer, the basis for which is uncertain. For example, a study by Gheorghe et al43 conservatively estimated the loss of QALYs to be 10-fold higher at 33 000 QALYs over 5 years, when considering the impact of diagnostic delay alone in the first twelve months of the pandemic for just four cancers.
