The backlog of cancer patients awaiting diagnosis and treatment: a post-pandemic NHS crisis?

Thousands of people with cancer have had their treatment disrupted during the Covid-19 pandemic. This article discusses the measures that can be taken by both healthcare professionals and the patient to reduce the impact.

The Covid-19 pandemic has put the NHS under the most extreme pressure seen in recent history.¹ And while hospitalisations are at an all time low, the NHS is now preparing to face an entirely new crisis.

For the past year, the NHS had to prioritise the huge influx of patients who were hospitalised with Covid-19. As a result, many areas of non-Covid care were forced to shut their doors or significantly reduce their capacity, meaning thousands of non-emergency appointments were cancelled.

On top of this, many GP surgeries also had to close and instead offered remote appointments as a first port of call, meaning physical examinations were happening much less frequently.

This combination of events has meant that countless numbers of patients did not receive the care they needed during the pandemic, with experts estimating that three million fewer elective treatments occurred in 2020 than usual.²

Doctors are particularly worried about the effect this will have on cancer patients, with a survey revealing that 74% of clinicians are concerned there is likely to be a ‘ticking timebomb’ of cancer patients waiting for diagnosis and treatment, as a result of Covid-19.³

The impact of Covid-19 on cancer activities

Cancer patients are known to be at higher risk of poor outcomes from Covid-19.⁴ Because of this, patients who had a cancer diagnosis were advised to stay away from healthcare settings in order to protect themselves from the virus.

Many in-person appointments were replaced with telephone consultations, and cancer screening services came to a halt. Before the pandemic, 200,000 people were being screened every week. Now that these screenings have been paused for over a year, experts believe there are around 50,000 people in the UK who are missing cancer diagnoses.⁵

Services such as endoscopies and scans were also reduced due to the extra time needed to clean and disinfect the necessary equipment. While NHS England insisted that urgent cancer treatment would remain unaffected, an analysis by Cancer Research UK found that every step of the cancer pathway has been disrupted by Covid-19.

There has been a particularly devastating impact on cancer surgeries. In the UK, approximately 36,280 cancer surgeries have been cancelled, with a 12-week cancellation rate of 28.8%.⁴ The NHS estimates an average of £4,000 per surgery, which means that clearing the backlog in cancer operations will cost over £145 million.⁴

Although it was recently announced (27th April) that cancer care would resume in the UK, the levels of care are still nowhere near where they should be. Instead, patients are now being assessed based on whether the risk of taking them into hospital outweighs delaying their treatment.

The impact of Covid-19 on cancer patients

Thousands of people with cancer have had their treatment disrupted. According to a survey by Macmillan, more than 650,000 (22%) cancer patients in the UK have experienced disruption to their cancer treatment or care.⁵

For around 150,000 people this included delayed, rescheduled or cancelled treatment. Of these, more than half (57%) said they were worried that delays to their treatment could affect their chance of survival. These concerns are well-founded, as delays to treatment are likely to have serious consequences for cancer patients. For example, one study relating to lung cancer suggests a 16% increase in mortality if the time from diagnosis to surgery is more than 40 days.⁵

Delays in treatment not only negatively impact physical health, but can also be harmful to patient’s emotional and mental wellbeing. Macmillan’s survey found that 41% of people whose treatment had been delayed or cancelled were stressed, anxious or depressed. This compares to just 25% of people who experienced no delays to treatment.

It is clear from the results of the survey, that drastic action will be needed in order to properly support cancer patients’ physical and emotional needs.

Cancer and the older patient

Older adults represent a large share of patients with cancer worldwide. In 2018, 6.6 million new cancer cases were diagnosed in people aged over 70 globally.⁶

Although there isn’t a lot of data on Covid-19 impacts on older patients with cancer, they are of particular concern to clinicians. This is because older patients with cancer typically have a worse prognosis than younger patients due to frailty and comorbidities.

Consequently, it is expected that delays to diagnosis and treatment will have severe consequences for older patients with cancer. Since older patients are particularly vulnerable to Covid-19, health professionals were advised to weigh up the risk-benefit balance when considering whether older cancer patients needed treatment in hospital.

If the risk of infection is high (‰¥2·5% per referral), for patients older than 70 years, the risk associated with investigatory referral might exceed the absolute survival benefit for tumour-referral groups with poorer outcomes.⁷

There is also likely a huge number of older patients who are missing a cancer diagnosis due to the digitalisation of doctor services. Since GPs were forced to operate remotely during the pandemic, experts warn some vulnerable groups will have found it more difficult to access care. A Healthwatch England report found that routinely offering remote appointments particularly disadvantages older people, especially those with dementia or sensory and communication impairments, as many do not have access to or know how to use technology.⁸

However, NHS England recently wrote a letter ordering GP practices to offer their patients face-to-face appointments, unless there are good clinical reasons on the contrary.⁹ With more in-person appointments happening, more timely diagnoses should be made, enabling clinicians to catch cancer in its early stages.

Predicted outcomes of delayed cancer services

Due to these delays in screening and treatment, many cancer patients will have a delayed diagnosis and as a result fewer treatment options and a lower chance of survival.

One study published by DATA-CAN and University College London estimated that the pandemic could result in additional 6,270 deaths over the next 12 months in people newly diagnosed with cancer.¹⁰This number rises to an estimated additional 17,915 additional deaths considering all people currently living with cancer.

There is also concern that healthcare professionals will hugely suffer, both mentally and physically, if they are expected to respond to this backlog without any respite from the pandemic.

Doctors and nurses around the globe are already exhausted and in need of a break, but their services remain high in demand and it’s likely to stay that way for the foreseeable future.

According to a survey, over half of doctors say their health and wellbeing is worse now than during the first wave of Covid. The same survey found that 41% of doctors are suffering from depression, anxiety or another mental health condition that has worsened during the pandemic, and 59% feel their current level of fatigue or exhaustion has been higher than normal.¹¹

It is fairly unsurprising therefore that around a quarter of doctors are likely to take a career break or seek early retirement in the next 12 months, while almost a fifth of doctors are considering leaving the NHS altogether.¹¹

What needs to be done?

For staff

The NHS has an enormous job on its hands, especially considering the pressure staff have been under since the start of the pandemic. Healthcare professionals have been tasked with getting services back to pre-pandemic levels, while also juggling the constraints that come with Covid, such as enforcing social distancing and disinfecting all surfaces and equipment on a regular basis.

It is clear that urgent action is required in order to address the backlog. However, this action must take into account the needs of NHS staff who are already suffering from burnout and fatigue.

For this reason, a long-term investment plan must be implemented to create a sustainable cancer workforce. This plan must include a full range of physical, emotional and practical support for both NHS staff and cancer patients themselves.

For cancer patients:

Firstly, cancer patients must be prioritised based on the urgency of their care needs. Serious cases, especially those which are life threatening, must be fast-tracked in order to reduce mortality rates as much as possible.

Secondly, the government must continue to campaign to encourage people to begin using health services again. It is only in this way that we can get the number of people seeing their GP with suspected cancer symptoms back to normal levels.

The NHS must also use sites that are safe for cancer patients to visit, in order to ensure they receive their treatment while remaining protected from the virus. One study suggests utilising private sector capacity in order to increase the amount of spaces which are free of Covid-19.⁴

Finally, the communication between patients and health services needs to improve in order to involve individuals in their care plan and ensure they are receiving the support they want and need.

Ultimately, as Macmillan say, the government must ensure that health inequalities do not widen as a result of the pandemic, and that no person with cancer ends up getting left behind.

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Lauren Nicolle is a senior reporter, GM Journal

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References

1. King’s Fund, 2021, ‘The NHS is now under the most extreme pressure seen in recent history’: The King’s Fund responds to the latest emergency care situation reports and estates data, accessed May 2021: https://www.kingsfund.org.uk/press/press-releases/nhs-now-under-most-extreme-pressure-seen-recent-history
2. Chaand Nagpaul, 2021, Doctor’s require respite, accessed May 2021: https://www.bma.org.uk/news-and-opinion/doctors-require-respite
3. Fujifilm, 2021, Clinicians concerned over potential ‘ticking timebomb’ of cancer patients and ‘significant’ waiting times for endoscopies due to COVID-19, accessed May 2021: https://www.prnewswire.com/es/comunicados-de-prensa/clinicians-concerned-over-potential-ticking-timebomb-of-cancer-patients-and-significant-waiting-times-for-endoscopies-due-to-covid-19-814060464.html
4. Ben Richardson, Scott Bentley, 2020, Cancer post-COVID: impact, outcomes and next steps, accessed May 2021: https://www.carnallfarrar.com/analytics/analytics-insights/cancer-post-covid-impact-outcomes-and-next-steps/
5. Macmillan, 2020, The Forgotten ‘C’? The impact of Covid-19 on cancer care, accessed May 2021: https://www.macmillan.org.uk/assets/forgotten-c-impact-of-covid-19-on-cancer-care.pdf
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252080/
7.  Sud et al., 2020, Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study, accessed May 2021: https://www.researchgate.net/publication/343091023_Effect_of_delays_in_the_2-week-wait_cancer_referral_pathway_during_the_COVID-19_pandemic_on_cancer_survival_in_the_UK_a_modelling_study
8. Healthwatch, 2021, GP access during COVID-19, accessed May 2021: https://www.healthwatch.co.uk/report/2021-03-22/gp-access-during-covid-19
9. NHS England, 2021, UPDATED STANDARD OPERATING PROCEDURE (SOP) TO SUPPORT RESTORATION OF GENERAL PRACTICE SERVICES, accessed May 2021: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/B0497-GP-access-letter-May-2021-FINAL.pdf
10. Alvina G. Lai et al., 2020, Estimating excess mortality in people with cancer and multimorbidity in the COVID-19 emergency, accessed May 2021: https://www.researchgate.net/publication/340984562_Estimating_excess_mortality_in_people_with_cancer_and_multimorbidity_in_the_COVID-19_emergency
11. British Medical Assocation (BMA), 2021, COVID-19: analysing the impact of coronavirus on doctors, accessed May 2012: https://www.bma.org.uk/advice-and-support/covid-19/what-the-bma-is-doing/covid-19-bma-actions-and-policy/covid-19-analysing-the-impact-of-coronavirus-on-doctors