Cancer Diagnosis and Treatment Upended by COVID-19, Says CRUK

Liam Davenport

April 28, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Routine cancer care, from screening and diagnostic tests in suspected cases to treatment of known cases with surgery and chemotherapy, has been substantially disrupted as a result of the COVID-19 pandemic, warns an expert from a leading UK charity, Cancer Research UK (CRUK).

Sara Hiom, CRUK's director of cancer intelligence, early diagnosis, and clinical engagement, says this is taking its toll on patients and healthcare workers alike.

She suspects that there are thousands of cancer cases going undiagnosed or untreated because of a lack of healthcare staff, fears over infection risk, and patients with signs and symptoms not coming forward.

Writing in a blog post published by CRUK on April 21, Hiom says this is causing "huge anxiety" to patients and having a psychological impact on physicians unable to "offer the comfort and reassurance they'd like."

The issue has been building since the COVID-19 pandemic hit the UK.

Earlier this month, consultant oncologist Karol Sikora, MD, PhD, warned that patients in certain areas of the country were not receiving chemotherapy and operations were being put on hold. Sikora, who is chief medical officer at Rutherford Health, which runs several oncology centers, told The Guardian newspaper on April 4 that treatment had become "inconsistent," with some hospitals having put "blanket bans on cancer treatment."

"Not everyone needs to rush ahead with cancer treatment, but others need to continue despite this to get the best long-term cure," he said.

Disruptions at All Points on Cancer Pathway

In her post, Hiom details how the COVID-19 pandemic has affected many aspects of cancer care in the UK right along the care pathway.

Alongside screening services being officially "paused" in Scotland, Wales, and Northern Ireland, she says they are "effectively paused" in England because invitations to screen are not being sent out.

This means that around 200,000 people are no longer being screened for colorectal, breast, and cervical cancer across the UK every week.

She warns that as a consequence "there will be a significant number of early cancers left undetected before these programs can be reintroduced," particularly in the early stages "when treatment is more effective."

The issue of cancer screening being halted was recently discussed on Medscape by Yale pathologist Benjamin Mazer, MD. He argues that the pandemic offers "a natural experiment like no other" and wonders if the break in screening will result in more advanced cancer being diagnosed, and whether that will affect outcomes.

In her blog, Hiom also reports that patients are not presenting with signs and symptoms indicative of cancer. The drop in numbers of people visiting their physician with symptoms affects "the whole diagnostic pathway." Urgent referrals for cancer have dropped by around 75% in England since the pandemic started.

Additionally, physicians are reluctant to send their patients to the local hospital in case they contract COVID-19, and many diagnostic tests such as endoscopy, bronchoscopy, guided biopsies, and computed tomography, are not taking place to protect patients and staff.

Hiom estimates that, as a result, 2300 cancer cases are going undiagnosed across the UK, a figure that "will be stacking up over time."

Cancer Surgery Being Delayed

Patients already diagnosed with cancer have been hit hard by the pandemic.

Despite national guidelines saying that urgent and essential cancer treatment must continue, those waiting in particular for surgery have had, in some hospitals, their appointments canceled or delayed by 3 months or more.

"We've been hearing that patients requiring major surgery aren't able to have it as either there are no recovery beds with ventilation, no [intensive care unit] beds if surgery were to go wrong, or because the surgery is just too risky for patients and staff," Hiom writes.

"Unfortunately, these issues are heavily affecting those who might benefit from surgery the most, as many 'curative' operations are complex," she continues.

There are also cases of chemotherapy and palliative care being affected by the COVID-19 pandemic, with either fear over the risks of infection or a lack of staff preventing high-priority treatment.

Comments on the CRUK post from patients with cancer and relatives show the anxiety that has resulted.

Patricia Matthewman said her son was diagnosed with cancer on March 17 and was told he needed chemotherapy "ASAP."

However, 2 weeks later he was told his treatment was postponed "until further notice."

"How are we supposed to live with this," she writes. "He is 47 years old with a wife and 2 children. I am terrified."

Another woman, who has secondary breast cancer, said all her appointments with her oncologists have been canceled and her personal physician called her to make sure she has an advance do not resuscitate order.

She writes that she is "literally being left to die."

Some oncologists have tried to "mitigate some of this disruption," Hiom writes. For example, some are using hormone therapy or radical radiotherapy instead of surgery for some cancers.

How One Oncologist Has Adapted  

One oncologist who has adapted his practice in response to the pandemic is Clive Peedell, MD, from the James Cook University Hospital, Middlesbrough, UK, and cofounder of the National Health Action Party. In a series of posts on Twitter, he explains that he has switched to teleconsultations for routine and treatment follow-up, but still has in-clinic visits for most of his new patients and those he is worried about.

"To be fair, this could be a good new way to do a lot of my work in future," he says.

https://twitter.com/cpeedell/status/1252902989804851200?s=21

However, Peedell acknowledged that it has been "a new tough new world for oncologists" in terms of treatment decisions.

"We lack the data to accurately guide us and we are taking a pragmatic approach based on national and international expert consensus opinion," he added.

https://twitter.com/cpeedell/status/1252902991176380416?s=21

Peedell notes that he is giving less chemotherapy and has stopped adjuvant chemotherapy for patients with lung cancer after surgery, which will reduce the cure rate "by at least 5% in these patients."

On a more positive noted, Peedell adds: "Interestingly, I'm actually giving more lung cancer radiotherapy than ever before, because the surgeons are operating much less due to #COVID19 risks, and we can use stereotactic radiotherapy to treat early stage lung cancer as a very good alternative to surgery."

https://twitter.com/cpeedell/status/1252902994762489856?s=21

No funding or conflicts of interest declared.

Cancer Research UK. How coronavirus is impacting cancer services in the UK. Published online April 21, 2020. Blog

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