The Effects of Cancer Delays During the COVID-19 Pandemic

Cancer is the leading cause of deaths globally. In 2020, there were just over 19 million cases and 10 million deaths worldwide.

Reduction in modifiable risk factors such as stopping smoking and early identification through screening can considerably reduce the burden of cancer.  However, access to diagnostics and timely referral for treatment can radically improve outcomes. The consequences for people with cancer can be devastating if access to effective therapies is delayed.

Specific symptoms such as persistent cough, change in bowel habit, unexplained weight loss suggests cancer. In primary care, we call these ‘red flags’. We use these red flag symptoms to identify high-risk individuals, ensuring they access early diagnostics and treatment to improve their overall chances of survival.

The results of our review of the impact of restrictions on cancer services highlight that global access to care was substantially reduced for various cancers. Because of the delays, late-stage cancer presentations increased, even after restrictions were lifted.

From mid-March until the end of April 2020, a cervical cancer screening unit in Cameroon saw screening numbers drop by nearly 80%.  This is troubling because late-stage presentations are linked to decreased cervical cancer survival. The five-year survival rate for US women diagnosed with advanced cervical cancer is 15% compared with 93% for those presenting much earlier with localized disease. A similar outcome is seen In low-income countries. In India, for example, the 5-year survival is 9% for advanced disease compared with 78% when the cancer is diagnosed at stage 1 when it is localized to the cervix.

Several studies in our review reported that when routine services resumed after restrictions were lifted, there was still a shift to later-stage disease presentations, even in countries that were relatively unaffected by the pandemic.

In a Japanese regional treatment centre, no significant changes were seen in the number of patients undergoing surgery. However, the number of patients undergoing surgery with advanced disease increased compared with before the emergency. In three university-affiliated hospitals in Korea, the number of cancers diagnosed remained the same; however, the proportion of patients with stage III-IV non-small-cell lung cancer (NSCLC) increased to 75% compared to an average of 63% in the three previous years.

Not all cancers have the same prognosis but presenting late with lung cancer is bad news. In those with early disease, more than 55 out of 100 people will survive for 5 years or more after diagnosis. But in later stage 4 disease – which has spread beyond the lungs – only five out of 100 survive for five years or more.

In low resource settings, delays had lethal effects. Among Indian patients presenting to a tertiary care hospital with oral cancers, 39% were deemed inoperable in the early three months of the COVID-19 pandemic – double the number compared with the pre-COVID-19 era.

These delays in care were not restricted to adults as children were affected in a variety of countries. In Turkey, a major Paediatric Oncology Department reported reductions in children undergoing chemotherapy, radiotherapy, surgery, and imaging studies during the COVID-19 period. In Italy, presentations to the National Pediatric Oncology Unit in Milan during the lockdown phase were half of what would normally be expected. And in a US tertiary referral centre, 75% of new leukaemia/lymphoma diagnoses required intensive care in April 2020 compared with a monthly average of 12% in 2018–2019.

Patients with cancer often delay seeking medical advice. The early phase of the Covid 19 pandemic substantially exacerbated these delays. The true extent of the impact of these delays may never be known. However, a substantial body of evidence reports that delays lead to later-stage cancer, which translates into more severe disease and subsequently reduces life expectancy. Low and middle-income countries are disproportionately affected by cancer, where more than two-thirds of all global deaths occur.

Early recognition of those with red flags symptoms and maintaining access to effective cancer care is essential for maintaining health and wellbeing. Our review found 69 published studies done in 23 countries that compared changes in the pattern of screening, diagnosis, waiting lists and treatments for cancer in the first wave of the covid pandemic. This evidence shows a consistent global drop in access to cancer care. Limitations of the review are linked to the inevitable observational nature of included studies and the possibility of publication bias which we cannot discount. Future pandemic policies should account for and mitigate against any delays in cancer care due to restrictions.

We plan to update this review.

Carl Heneghan is Professor of Evidence-Based Medicine, University of Oxford and an advisor to CG. Disclosure statement is here

Tom Jefferson is an Epidemiologist. Disclosure statement is here

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