COMMENTARY

What Will Happen to Cancer Services in 2021?

Prof Karol Sikora

Disclosures

December 24, 2020

This transcript has been edited for clarity.

Hello, it's Professor Karol Sikora here, talking about 2021. The future.

My specialty is oncology, but everything has to be interpreted in the slipstream of COVID.

At the moment, it's just before Christmas, and COVID is rampant everywhere. It's on all the news channels, 24-7 rolling news, the hospitals are full of it.

In the UK, around 20% of all NHS beds are occupied by COVID admissions. Having said that, it's not quite as bad in that some of the patients that are billed as having COVID would be in hospital anyway for other things. So it's a combination. Many are elderly with complex comorbidities, and some of them even caught COVID in the hospital whilst they were treated for something else.

How does it affect cancer? Well, at the moment, cancer services are OK superficially. The real problem is will we have to go to a drastic reduction in the output of operations for cancer, which is what happened way back in April where the diagnosis of cancer plummeted.

Normally there are 1000 patients a day, 30,000 a month. In the month of April, there were less than 5000 in 2020.

What will we see, as we go forward?

I predict that in January there'll be a drop, a considerable drop, as we come out of it.

By February, the vaccination strategy, the increased prevalence of the virus, and the recovered population, will also go up, which means we'll be approaching some form of herd immunity.

And once we get there, then the clinical importance of COVID will drop.

The other fascinating bit of information is looking at the Office for National Statistics data in the UK. The first peak of mortality is very clear to see - April May and June of 2020. But this peak around Christmas time doesn't really exist. There is a slight uptick, but not a great one.

And I think that just reflects a different, milder illness.

Sure, we're getting better at treating it. But it's not just that, there's something else going on.

And so the number of deaths have been less, and therefore the implication for health service use is also reduced. It's also reflected in ventilator bed usage. If we looked at the ventilator bed usage, although there are something like nearly 20,000 people in hospital, it's clear that the number of patients on ventilators as a percentage of that is much lower than in the April peak, so something else has changed.

So what's going to happen for cancer?

Well, my predictions are as follows:

The month of January, there'll be a drop to about 20,000 new patients with cancer. We'll have all the same problems - the COVID testing of staff, of patients before they start adjuvant therapy with either radiotherapy or chemotherapy.

The main drivers of adjuvant chemotherapy are breast and colon cancer, together with a small amount of lung cancer.

The main drivers of radiotherapy are of course lung cancer, and prostate cancer, and then a whole range of other cancers. But numerically, these are the big drivers of workload.

Back to Normal?

By February, I would predict the numbers will pick up to near normal, and by March we'll be back to normal.

There'll be a bit of a bottleneck in February, as new patients need to get started on postoperative adjuvant therapy. What else will happen?

It's likely that some of the abbreviated courses will stay throughout 2021. And there’s certainty that distance outpatient clinics, which everyone actually finds convenient - the patients love it, the doctors love it, people can do it from home if necessary, they can do it from anywhere, they can do it on their mobile phone. It does require a different form of consultation, a different way of giving empathy. And that is important to teach. And I think what we'll have to do in 2021 is go through empathic learning using video links. And, you know, an afternoon spent with critique by colleagues is probably something really worth doing. It's not difficult to do, after all the media people, the newscasters, do media training all the time. We can do the same thing.

And so we can sound more sympathetic on the phone. I think that the key message to sounding sympathetic is to do only one thing, don't multitask while you're talking to patients. And ideally, if you can, do it visually, as well as by sound on a telephone. It’s so much better if you can see someone talking, especially if they're telling you things of absolutely vital importance, of your prognosis or treatment, and what's going to happen to you next.

So, moving forward, by June, I think we'll be nearly back to normal in terms of cancer. Other services again, the same, and that we streamline. So we'll gain by streamlining some of the referral services to move the whole thing forward.

Will things change?

Well, short courses of chemotherapy and radiotherapy will be there, five-fraction regimens, SABR treatments, proton beam therapy, and of course, the MR Linac will be out there to deliver more precise but shorter versions of treatment.

So short course formats for a whole range of treatments will become the norm. And you know, in radiotherapy, five-fractions hyperfractionated, not SABR necessarily, but just hyperfractionated treatment, even for palliation. As certainly for certain radical treatments of breast, lung, and prostate will be the way we'll move forward.

And we can do it now - more precision radiotherapy means shorter courses - if we want to do so.

And the difficulty is formal clinical proof. Luckily, for both prostate and breast, there are some good trials, which are nearing completion, and we can get that data and show that five versus 25 is more or less the same as 15 in the middle for breast and that's clearly the way forward.

As we go through 2021. By June, near normality will be there, we’ll be at herd immunity with vaccination and infection.

And I think radiotherapy and chemotherapy services will be, will be normal everywhere throughout Europe.

Diagnostics

The biggest problem, as always, in the UK, is the diagnostics. And it's simply a matter of not having enough here. We’ve got to get more diagnostics to reduce the stage of presentation of cancer in Britain compared to the rest of Europe, which means we still have poorer survival statistics.

It's nothing to do with the quality of treatment, or the doctors or their education, it’s simply late stage presentation. A stage shift of one stage means it explains everything in terms of mortality at all age groups. So getting that shift is important. The 2-week wait, no one's ever heard of that in Europe. It's like explaining rain to fish. Why would you wait 2 weeks to get a CT scan? You just don't have to do it in France. We do here. And that's the whole problem. We've got to get out of that mentality. I mean, building more units, servicing the units we have longer, getting more staff, and ultimately paying more for better cancer diagnostics.

That's got to be the message for 2021, and indeed the whole of the next decade, is righting the huge deficit in cancer diagnostics that Britain has, to keep up with mainland Europe.

This is Karol Sikora. Thank you for listening.

You can follow Prof Karol Sikora on Twitter

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