One of the biggest losers in the fight against COVID-19 has been the fight against cancer. The virus has thrown healthcare systems around the world into disarray. In the United Kingdom, hospitals have been redesigned to maximize social distancing and to treat COVID-19 victims. Non-urgent care has been paused, as doctors and nurses have been redeployed in the effort against the pandemic. National screening programs for cancer effectively ceased to exist for three months.
This has all contributed to fewer people being diagnosed with cancer, let alone treated. Simply put, the earlier someone is diagnosed with cancer, the more likely they are to survive. In England, a person who is diagnosed with stage 1 or 2 cancer has an 80% chance of surviving for five years or more. But if you are only diagnosed when cancer has reached stage 3 or 4 – this survival rate drops to 40%.
About 7,000 people are usually diagnosed with cancer each week in the UK. But this number dropped dramatically during the first lockdown. Cancer Research UK has estimated that 2,700 fewer people are being diagnosed with cancer each week in the UK.
This drop is due to a number of reasons. Scotland, Wales, and Northern Ireland all paused their national screening programs for cancer during the lockdown. England too paused their screening program as they stopped sending invitations.
Certain diagnostic measures were also paused like endoscopies, for fear that their intrusive nature may contribute to the spread of COVID-19. The lack of social contact with loved ones makes it easier for people to ignore symptoms. Often, family and friends push patients to visit a doctor, however, social distancing has prevented these important conversations from happening.
Many people have also stopped talking to their GPs, as consultations moved to the phone. During the peak of the pandemic in April only 80,000 people were referred by their GP to a consultant cancer specialist, as opposed to 200,000 people who had been referred to the previous April.
Some do not want to burden the healthcare system. They have watched news coverage of stretched and under-resourced hospitals battling the disease and seen interviews with fatigued health care professionals. They worry about adding to the burden. Others do not want to visit the doctor for fear of catching COVID-19.
Similar trends have been observed worldwide. In the Netherlands, cancer diagnoses dropped dramatically after the first case of COVID-19 was reported in the country. The rate of skin cancer diagnosis dropped the most. In Italy, cancer diagnoses fell by 39% during lockdown, compared to the two previous years. According to Quartz, stats from 270 community oncology practices in the US showed that patient visits fell by 40% in April.
Treatment which involved weakening the immune system was paused for much of lockdown. For example, all CAR-T cell therapies were paused as intensive care unit beds were needed to help COVID-19 patients recover.
But in the last few weeks, the government has been trialing new ways to make treating cancer easier.
Two temporary hospitals that had been initially constructed to deal with COVID-19 patients have now been converted to cancer wards in an effort to reduce the backlog of cancer cases. One is a 200-bed hospital in Exeter, while the other holds 500 patients in North Yorkshire. The latter has been offering CT scans for suspected cancer sufferers since early June.
NHS England also announced that stereotactic ablative radiotherapy (SABR) will be available to access the entire NHS by the end of the financial year. The therapy requires fewer doses than standard radiotherapy, and its full rollout was initially planned for 2022. The therapy works predominantly on non-small cell lung cancer.
The NHS has also rolled out four chemo-buses which allowed patients to take part in therapy without entering a hospital. The focus throughout has been to prioritize treatment with the greatest clinical benefit and the minimal number of hospital visits.
Cancer Research UK says in order to bring levels of cancer treatment back to normal; the priority should be to create COVID-protected safe spaces in hospitals. These spaces would work by having anybody who works within them- tested frequently. These spaces would also be deep cleaned frequently.
According to the charity’s analysis, between 21,000 and 37,000 tests would need to be done per day to test all cancer patients and staff at a frequency of once a week. Neither tThe government nor the NHS have commented on these figures.
Social distancing will be with us for the foreseeable future and as minimizinge the spread of COVID-19 will continue to be a priority. New therapies that minimize hospital visits may have to be prioritized by pharmaceuticals and MedTech companies.
Dealing with the backlog of cancer treatments while simultaneously dealing with new cases will be the main struggle faced by healthcare systems.
New clinical trials were also put on hold. Clinical trial patient recruitment fell by 95% in April 2020, compared to April, the year before. Clinical trials were paused so that clinical staff could be redeployed to the frontline. Cancer patients were also thought to be the most vulnerable to COVID-19 and so were told to ‘shield’ for 12 weeks, making it harder for them to take part in extensive trials.
Cancer Research UK, which funds around 50% of research in the UK, say they will suffer a £150 million shortfall in fundraising this year. They note that this is the amount of money they would spend on clinical trials for the next ten years.
This shortfall in money will mean that they will not be able to fund as many PhD and postdoctoral positions in the future – leading to a brain drain in the field.
Making up for lost time
Writing in Nature Cancer, Dr Gary Doherty says the future of clinical trials for the foreseeable future, will revolve around virtual visits and consultations. It will also rely on couriers transporting drugs, rather than the patient visiting a pharmacist themselves.
Several regulations surrounding clinical trials have been loosened during COVID-19, particularly in the US. The FDA previously mandated that all drug-taking and all monitoring of patients be done in person by specific staff members. This forced doctors to only choose people who could easily and regularly visit the hospital.
It left out thousands of patients who lived in rural areas or did not have easy access to transport. It also led to a lack of diversity in Black and Hispanic patients. In light of the pandemic, the FDA loosened its rules, so that patients could consult with their doctors over the phone and take medication themselves from the safety of their homes.
Some doctors in the UK have also been calling patients more often to check in with them. But this approach comes with more challenges when doctors are faced with having more serious conversations about cancer.
One of the biggest issues coming out of lockdown will revolve around public messaging. How do you convince people to take cancer diagnosis seriously again? People are understandably nervous about healthcare settings and may feel like they don’t want to burden a system overwhelmed by COVID-19, but this view allows cancer to proliferate.
The government and cancer charities need to devise messaging that will get people to consider seriously the risk they are putting themselves in, by delaying a cancer diagnosis. It is not an easy task and will need to counter three months of messaging about staying at home.
The UK NHS has begun to take action. In October, the healthcare system developed a new campaign featuring celebrities, including Gordon Ramsey and Emma Thompson, and lockdown heroes who urged patients to have cancer symptoms checked by their doctors. Safety measures have also been put in place to help ensure patients can receive treatment.
Although we now have the promise of a vaccine, countries will still need to determine how to continue diagnosing and treating cancer patients as cases of COVID-19 rise. One example to look at is South Korea – which did not stop its cancer services at all during the height of the pandemic.
The country was able to do this in multiple ways. Hospitals devised triage units outside its buildings so patients could be first tested for a fever and breathing issues before entering the building. Nurses would also call cancer patients the day before their treatment and ask whether they displayed any coronavirus symptoms. Patients who required chemotherapy were also first tested for the virus. This system also relied on Korea’s extensive contract tracing and quarantine system.
New investments in CT scans, MRI scanners, and X-ray machines will also be required, as hospitals struggle to deal with the backlog of cancer diagnostics.
Ultimately – the impact that COVID-19 has had on cancer will not be truly understood for years. People who aren’t diagnosed with cancer as early as they might have been pre-pandemic, may not die for several years. But it is clear that the disease has impacted every stage of the fight against cancer.
Cancer has long been feared as the ticking timebomb of the pandemic thus far, it is up to everyone involved to ensure that we are as prepared as we can be.