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Impact of COVID-19 on colorectal cancer early diagnosis pathway: retrospective cohort study

Authors:
Mohamed Abdellatif at Kettering General Hospital NHS Foundation Trust
Mohamed Abdellatif
Yahya Salama at Kettering General Hospital NHS Foundation Trust
Yahya Salama
Tariq Alhammali at Kettering General Hospital NHS Foundation Trust
Tariq Alhammali
A M Eltweri
A M Eltweri
A M Eltweri
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Impact of COVID-19 on colorectal cancer early diagnosis
pathway: retrospective cohort study
M. Abdellatif
1
*, Y. Salama
1
, T. Alhammali
1
and A. M. Eltweri
2
1
General Surgery Department, Kettering General Hospital, Kettering NN16 8UZ, UK
2
Leicester General Hospital, Gwendolen Rd, Leicester LE5 4PW, UK *
Correspondence to: General Surgery Department, Kettering General Hospital, Rothwell Road, Kettering Northants NN16 8UZ, UK
(e-mail: mohamed.abdellatif@nhs.net)
Editor
Non-emergency services offered by the National Health Service were
significantly affected during the COVID-19 pandemic
1
.Concerns
were raised about the impact on care of other groups of patients who
require time-critical intervention, such as those with suspected colo-
rectal cancer
2
. These patients are referred through rapid-access path-
ways for diagnostic investigations, according to certain criteria
specified by national guidelines
3
.Itisfearedthatthispathwaywas
compromised during the COVID-19 period. This study examined the
impact of the COVID-19 pandemic on the (colorectal cancer) early di-
agnostic pathway, and subsequent delays in diagnosis and treatment
of these patients in Kettering General Hospital.
Patients referred with suspected colorectal cancer via the 2-
week wait pathway, between 1 March and 31 July 2020, were
compared with those referred during the equivalent period in
2019. The following parameters were compared: total number of
referrals, time to first appointment, time from referral to diagno-
sis, and percentage of patients who achieved a diagnosis within
28 days and referral to treatment (RTT).
A total of 460 patients were included in the 2020 cohort, com-
pared with 808 in the 2019 cohort (43.1 per cent drop). The most
significant decrease was noticed in April 2020 during the peak of
the pandemic.
Some 90.0 per cent of first appointments were conducted
within 2 weeks of referral in 2020 compared with 97.0 per cent in
2019. It is worth highlighting that half of the clinic appointments
were made virtual (49.0 per cent) to mitigate the impact of
COVID-19.
The diagnosis target was achieved in 70.4 per cent of patients
in 2020 versus 88.0 per cent in 2019. The mean time from referral
to diagnosis was significantly higher in the COVID cohort (Fig. 1).
The total number of delays was 136 (29.6 per cent) in 2020 com-
pared with 97 (12.0 per cent) in 2019. COVID-19 was the docu-
mented reason for delay in 78 (57.4 per cent) of the pandemic
cohort. This meant that 10 of 22 patients requiring cancer treat-
ment missed their RTT target of 62 days in the COVID-19 cohort
compared with only 2 of 14 in the pre-COVID-19 cohort.
Surprisingly, the yield of cancer diagnosis increased by 35.4 per
cent during the COVID-19 period despite the reduced number of
referrals. This may indicate that the fear of missing a cancer di-
agnosis might be exaggerated. However, this assumption must be
examined cautiously by future studies to detect surges in
patients with delayed presentations.
The delay in diagnosis and starting treatment is definitely a
big concern. Sud and colleagues
4
reported that a 3-month delay
in diagnosis of colorectal cancer would result in at least a 10.0
per cent drop in 10-year survival rates.
Lessons should be learnt from the first-wave experience to
mitigate the impact of any future lockdowns. Developing triage
systems using alternative tests, such as the faecal immunochem-
ical test, in primary care helped stratify patients into highest or
lowest risk of bowel cancer
5
. Virtual clinics and telemedicine
were introduced across the country to help tackle similar prob-
lems. Straight to test is another channel that general practi-
tioners (GPs) can use in patients with strongly suspected
pathology. To a similar extent, educational media campaigns to
urge people to seek help when needed are vital to prevent
patients delaying presentation to a GP.
Disclosure
The authors declare no conflict of interest.
50
2019
2020
March April May June July
Average time (days)
45
40
35
30
25
20
15
10
5
0
Fig. 1 Mean time from referral to diagnosis for each month
Received: October 11, 2020. Accepted: November 15, 2020
V
CThe Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved.
For permissions, please email: journals.permissions@oup.com
2BJS, 2021, 1–2
DOI: 10.1093/bjs/znaa122
Research Letter
References
1. Courtney A, Howell AM, Daulatzai N, Savva N, Warren O, Mills S
et al. Colorectal cancer services during the COVID-19 pandemic.
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et al. The impact of the COVID-19 pandemic on cancer deaths due
to delays in diagnosis in England, UK: a national, population-
based, modelling study. Lancet Oncol 2020;21:1023–1034
3. National Institute for Health and Care and Excellence (NICE).
Colorectal Cancer: Diagnosis and Management. London: NICE, 2014.
4. Sud A, Torr B, Jones ME, Broggio J, Scott S, Loveday C et al. 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. Lancet Oncol 2020;21:1035–1044
5. Lee YH, Kung PT, Wang YH, Kuo WY, Kao SL, Tsai WC. Effect of
length of time from diagnosis to treatment on colorectal cancer
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2|BJS, 2020, Vol. 00, No. 0
... Straight-to-test is another channel that general practitioners (GP) can use for patients with suspected oncologic disease (O'Donohoe et al. 2021). For this reason, educational media campaigns to urge people to seek help when needed are vital to prevent patients delaying or avoiding contact with a GP (Abdellatif et al. 2021). In fact, the emphasis on social distancing might have inappropriately convinced patients to avoid in-person medical care, in addition to the suspension of medical services, which made it more complex for outpatients to get an appointment (Reichardt et al. 2021). ...
... The reduction of oncologic visits found in our analysis is likely to be associated with a longer time interval from symptom onset to referral and to diagnosis, a phenomenon reported elsewhere (Abdellatif et al. 2021), that combined with the decrease in cancer screening programs (Teglia et al. 2022a), in visits by general practitioners and in diagnostic procedures (Angelini et al. 2023), is expected to lead, according to the UK Health and Social Care Commettee (2022), to underdiagnosis and undertreatment of cancer and additional cancer deaths (Fonseca et al. 2021). Hospital admissions of oncologic patients showed a global significant decrease, reaching a nadir in May 2020. ...
Decrease of visits and hospital admissions for cancer patients during the COVID-19 pandemic. A systematic review and meta-analysis
Article
Full-text available
  • Mar 2023
  • J Publ Health
Background During the COVID-19 pandemic, many nonurgent oncologic services were postponed. The aim of the present study was to estimate the impact of the pandemic on visits and hospital admissions for cancer patients worldwide. Methods In our systematic review and meta-analysis, databases such as Pubmed, Proquest, and Scopus were searched comprehensively for articles published between January 1, 2020, and December 12, 2021. We included articles reporting data comparing the number of visits and hospital admissions for oncologic patients performed before and during the pandemic. Two pairs of independent reviewers extracted data from the selected studies. The weighted average of the percentage change was calculated and compared between pandemic and pre-pandemic periods. Stratified analysis was performed by geographic area, time interval, and study setting. Findings We found a mean relative change throughout January–October 2020 of –37.8% (95% CI –42.6; –32.9) and –26.3% (95% CI –31.4; –21.1) compared to pre-pandemic periods for oncologic visits and hospital admission, respectively. The temporal trend showed a U-shaped curve with nadir in April for cancer visits and in May 2020 for hospital admissions. All geographic areas showed a similar pattern and the same was observed when stratifying the studies as clinic-based and population-based. Interpretation Our results showed a decrease in the number of visits and hospital admission during the January–October 2020 period after the outbreak of the COVID-19 pandemic. The postponement or cancellation of these oncologic services may negatively affect the patient’s outcome and the future burden of disease.
View
... Besides underdiagnosis [19], the probable consequence of the suspension of cancer care service, together with the lengthening of the time interval from referral to diagnosis [20], is a shift to higher-stage tumors. In the acute phase of the pandemic, the "lockdown" measures and the people's fear of the infection, brought to a selection of the patients presenting at the hospitals, which were more likely to be the ones with serious concerns for their health. ...
... The phenomenon of aggressive risk-aversion, through public announcements that urged people to stay at home at almost any cost, is probably one of the most important causes of the outcomes outlined in our analysis. Studies published elsewhere (20,26) suggested that this behavior can harm people and that educational media campaigns to encourage people to seek help when needed, are vital to prevent patients late presentation to a GP. ...
Decrease of cancer diagnosis during COVID-19 pandemic: a systematic review and meta-analysis
Article
Full-text available
  • Jan 2023
  • EUR J EPIDEMIOL
Many health services, including cancer care, have been affected by the COVID-19 epidemic. This study aimed at providing a systematic review of the impact of the epidemic on cancer diagnostic tests and diagnosis worldwide. In our systematic review and meta-analysis, databases such as Pubmed, Proquest and Scopus were searched comprehensively for articles published between January 1st, 2020 and December 12th, 2021. Observational studies and articles that reported data from single clinics and population registries comparing the number of cancer diagnostic tests and/or diagnosis performed before and during the pandemic, were included. Two pairs of independent reviewers extracted data from the selected studies. The weighted average of the percentage variation was calculated and compared between pandemic and pre-pandemic periods. Stratified analysis was performed by geographic area, time interval and study setting. The review was registered on PROSPERO (ID: CRD42022314314). The review comprised 61 articles, whose results referred to the period January–October 2020. We found an overall decrease of − 37.3% for diagnostic tests and − 27.0% for cancer diagnosis during the pandemic. For both outcomes we identified a U-shaped temporal trend, with an almost complete recovery for the number of cancer diagnosis after May 2020. We also analyzed differences by geographic area and screening setting. We provided a summary estimate of the decrease in cancer diagnosis and diagnostic tests, during the first phase of the COVID-19 pandemic. The delay in cancer diagnosis could lead to an increase in the number of avoidable cancer deaths. Further research is needed to assess the impact of the pandemic measures on cancer treatment and mortality.
View
... Besides underdiagnosis (11), the probable consequence of the suspension of cancer care service, together with the lengthening of the time interval from referral to diagnosis (12), is a shift to higher-stage tumors. In the acute phase of the pandemic, the "lockdown" measures and the people's fear of the infection, brought to a selection of the patients presenting at the hospitals, which were more likely to be the ones with serious concerns for their health. ...
... The phenomenon of aggressive risk-aversion, through public announcements that urged people to stay at home at almost any cost, is probably one of the most important causes of the outcomes outlined in our analysis. Studies published elsewhere (12,18) suggested that this behavior can harm people and that educational media campaigns to encourage people to seek help when needed, are vital to prevent patients late presentation to a GP. ...
Decrease of cancer diagnosis during COVID-19 pandemic: a systematic review and meta-analysis.
Preprint
Full-text available
  • Jul 2022
Background: Many health services, including cancer care, have been affected by the COVID-19 epidemic. This study aimed at providing a systematic review of the impact of the epidemic on cancer diagnostic tests and diagnosis worldwide. Methods: In our systematic review and meta-analysis, databases such as Pubmed, Proquest and Scopus were searched comprehensively for articles published between January 1st, 2020 and December 12th, 2021. Observational studies and articles that reported data from single clinics and population registries comparing the number of cancer diagnostic tests and/or diagnosis performed before and during the pandemic, were included. Two pairs of independent reviewers extracted data from the selected studies. The weighted average of the percentage variation was calculated and compared between pandemic and pre-pandemic periods. Stratified analysis was performed by geographic area, time interval and study setting. The review was registered on PROSPERO (ID: CRD42022314314). Findings: The review comprised 61 articles, whose results referred to the period January – October 2020. We found an overall decrease of -37.3% for diagnostic tests and -27.0% for cancer diagnosis during the pandemic. For both outcomes we identified a U-shaped temporal trend, with an almost complete recovery for the number of cancer diagnosis after May 2020. We also analyzed differences by geographic area and screening setting. Interpretation: We provided a summary estimate of the decrease in cancer diagnosis and diagnostic tests, during the first phase of the COVID-19 pandemic. The delay in cancer diagnosis could lead to an increase in the number of avoidable cancer deaths. Further research is needed to assess the impact of the pandemic measures on cancer treatment and mortality.
View
... RESULTADOS: 389 pacientes fueron incluidos, 169 en la cohorte 1 y 220 en la cohorte 2. El cribado del CCR y la anemia fueron las causas que llevaron al diagnóstico en más pacientes en la cohorte 1 y 2, respectivamente (p < 0,001). El retraso diagnóstico y terapéutico fue mayor en la cohorte 2 [6,4 (95% CI 5,9) vs. 4,8 (95% CI 4,[3][4][5]3) meses, p < 0,001]. En la cohorte pandémica hubo más pacientes que requirieron tratamiento urgente (15,5% vs. 9,5%, p = 0,080). ...
... Several authors have published their experience with the treatment of patients with CRC during the pandemic [1][2][3][4] , with most centres observing a drop in the number of patients with CRC diagnosed or treated during the pandemic [5][6][7][8][9][10][11][12][13][14][15][16][17][18] . One of the main reasons for this reduction was that most CRC screening programs were cancelled during the pandemic lockdown [19][20][21] . ...
¿Ha cambiado la pandemia de COVID-19 la presentación clínica y el estadio tumoral en el momento del diagnóstico en los pacientes con cáncer colorrectal? Estudio retrospective de cohortes
Article
  • Feb 2022
RESUMEN INTRODUCCIÓN: La pandemia de Enfermedad por Coronavirus 2019 (COVID-19) ha afectado al manejo de los pacientes con cáncer colorrectal (CCR). El objetivo de este estudio fue comparar el retraso diagnóstico, la sintomatología, y el estadio de los pacientes con CCR durante la pandemia con una cohorte histórica. MATERIAL Y MÉTODOS: Los pacientes valorados en el comité multidisciplinar de CCR entre septiembre de 2019 y enero de 2020 (cohorte 1) se compararon con los presentados entre septiembre de 2020 y marzo de 2021 (cohorte 2). RESULTADOS: 389 pacientes fueron incluidos, 169 en la cohorte 1 y 220 en la cohorte 2. El cribado del CCR y la anemia fueron las causas que llevaron al diagnóstico en más pacientes en la cohorte 1 y 2, respectivamente (p < 0,001). El retraso diagnóstico y terapéutico fue mayor en la cohorte 2 [6,4 (95% CI 5,8–6,9) vs. 4,8 (95% CI 4,3–5,3) meses, p < 0,001]. En la cohorte pandémica hubo más pacientes que requirieron tratamiento urgente (15,5% vs. 9,5%, p = 0,080). El estadio tumoral fue más avanzado en la cohorte 2 [ganglios positivos en el 52.3% vs. 36,7% (p = 0.002), y enfermedad metastásica en el 23,6% vs. 16,6% (p = 0,087)]. CONCLUSIÓN: Los pacientes con CCR en la cohorte pandémica tenían un retraso diagnóstico y terapéutico más largo y menos pacientes fueron diagnosticados en el cribado de CCR. Además, los pacientes con CCR durante la pandemia necesitaron tratamiento urgente con más frecuencia y su estadio tumoral fue más avanzado.
View
... Several authors have published their experience with the treatment of patients with CRC during the pandemic, [1][2][3][4] with most centres observing a drop in the number of patients with CRC diagnosed or treated during the pandemic. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] One of the main reasons for this reduction was that most CRC screening programmes were cancelled during the pandemic lockdown. [19][20][21] Moreover, endoscopy services also reduced their activity and fewer colonoscopies were performed during this time to diagnose patients with suspected CRC. ...
Has the COVID-19 pandemic changed the clinical picture and tumour stage at the time of presentation of patients with colorectal cancer? A retrospective cohort study
Article
  • Feb 2023
Introduction: Treatment of patients with Coronavirus Disease 2019 (COVID-19) has affected the management of patients with colorectal cancer (CRC). The aim of this study was to compare the diagnosis delay, symptoms, and stage of patients with CRC during the pandemic with a control cohort. Material and methods: Patients referred to the CRC multidisciplinary team between September 2019 and January 2020 (cohort 1, control group) were compared with those who presented between September 2020 and March 2021 (cohort 2, pandemic group). Results: 389 patients were included, 169 in cohort 1 and 220 in cohort 2. No differences were observed in the main characteristics of the patients. CRC screening and anaemia were the most common causes leading to the diagnosis of the tumour in cohort 1 and 2, respectively (p<0.001). Diagnostic and therapeutic delay was longer in cohort 2 [6.4 (95% CI 5.8-6.9) vs. 4.8 (95% CI 4.3-5.3) months, p<0.001]. More patients required non-elective treatment in the pandemic cohort (15.5% vs. 9.5%, p=0.080). The tumour stage was more advanced in patients in cohort 2 [positive nodes in 52.3% vs. 36.7% (p=0.002), and metastatic disease in 23.6% vs. 16.6% (p=0.087)]. Conclusion: CRC patients in the pandemic cohort had a longer diagnostic and therapeutic delay and less patients were diagnosed because of CRC screening. In addition, patients with CRC during the pandemic needed non-elective treatment more frequently than patients in the control cohort, and their tumour stage tended to be more advanced.
View
... In a systematic review of Mazidimoradi et al., the COVID-19 pandemic was found to have a negative effect both on the diagnosis and treatment of colorectal cancer [34]. Decreased diagnosis of new cases of colorectal cancer was seen in most countries, varying from 43.1% to 73.1% among different studies, with important discontinuities reported in screening programs and patients' usual visits [34][35][36][37]. Clinical studies found a significant increase in emergency presentations, for bowel obstruction or perforation [33][34][35]. ...
New Challenges in Surgical Approaches for Colorectal Cancer during the COVID-19 Pandemic
Article
Full-text available
  • May 2022
(1) Background: The COVID-19 pandemic put a great burden on national healthcare systems, causing delays and disruptions in the medical care of non-COVID-19 patients. This paper aims to analyze the COVID-19 pandemic impact upon the quality of care in colorectal surgery. (2) Materials and Methods: We performed a retrospective study on the colorectal cancer cases operated in the Fourth Department of General Surgery, Emergency Hospital Bucharest Romania, over the period March 2020–February 2021 (pandemic group) vs. March 2019–February 2020 (non-pandemic group). (3) Results: The number of patients in the pandemic group decreased by 70% (36 vs. 118 patients), with lower accessibility from rural areas (11.1% vs. 37.2%, p = 0.035). Most cases in the pandemic group were emergencies (69% vs. 37.3%, p = 0.009), admitted for bowel obstruction (63.8% vs. 27.9%, p = 0.008). There was no in-hospital COVID-19 infection in patients operated for colorectal cancer. The 30-day mortality was significantly higher in the pandemic group (25% vs. 6.7%, p = 0.017), mostly due to septic shock (36.1% vs. 5%, p = 0.0001). (4) Conclusions: Colorectal cancer surgery may be performed safely during the COVID-19 pandemic, with strict adherence to the SARS-CoV-2 prevention protocols. However, the significant increase in colorectal cancers in the emergency was associated with worse outcomes and higher mortality during the COVID-19 pandemic.
View
COVID-19 pandemic: Impacts on diagnosis and treatment of colorectal cancer
Article
Full-text available
  • Jan 2022
Introduction: Since its first strike in 2019, the highly contagious Sars-Cov-2 virus has not only directly caused millions of deaths in Vietnam but also indirectly affected many other diseases such as colorectal cancer. In order to clarify this statement, this study was conducted to investigate the difference in disease stage, curative rate of colorectal cancer before and after the Covid-19 outbreak.
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Impact Of The COVID-19 Pandemic on Time To Treatment Initiation For Colorectal Cancer In Japan
Preprint
Full-text available
  • Jul 2023
Purpose This retrospective study aims to evaluate potential differences of diagnosis and treatment of colorectal cancer between the two years before and after the onset of the COVID-19 pandemic. Methods Retrospectively enrolled in this study were consecutive patients with colorectal cancer who underwent surgery at our institution between April 2018 and March 2022 (Trial registration number: UMIN000051148 on May 23, 2023). Clinicodemographic data and short-term postoperative outcomes were collected for statistical analysis. Results This study included 383 patients (203 patients before the pandemic, 180 patients during the pandemic). During the pandemic, the time between initial symptoms and referral was 2 months or less in significantly fewer patients than before the pandemic. Patients who required at least 2 months to initial referral were significantly associated with the COVID-19 pandemic (OR 2.89, 95%CI 1.70–4.93, P˂ 0.001) and absence of fecal occult blood testing (OR 2.44, 95%CI 1.32–4.52, P = 0.005) in multivariate analysis. Conclusions This study demonstrated short-term outcomes of colorectal cancer surgery and risk factors of delay from initial symptoms to referral during the first two years of the COVID-19 pandemic. Specific risk stratification and guidance are recommended in the event of future pandemics to prevent poorer oncological outcomes in patients with colorectal cancer.
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Epidemiology of Stage IV Colorectal Cancer: Trends in the Incidence, Prevalence, Age Distribution, and Impact on Life Span
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  • Mar 2023
Colorectal cancer is a common malignancy in men and women. Historically, stage IV colorectal cancer has 10 to 15% five-year survival. Developments in the management of colorectal metastatic disease have helped improve the overall survival of stage IV colorectal cancers from 12 to 30 months with some patients achieving disease-free survival.
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The Impact of the COVID-19 Pandemic on Colorectal Cancer Patients in a Tertiary Center in Romania. Single Center Retrospective Study
Article
Full-text available
  • Feb 2022
  • Chirurgia
Background: The novel coronavirus, SARS-COV-2, was first reported in Wuhan, China in the end of 2019. To curb its spread, social distancing measures and new safety regulations were implemented which led to major disruptions in colorectal cancer care. It is however unknown how it influenced the Romanian colorectal cancer care. Methods and Material: We assessed the demographical, clinical, intraoperative and pathological data of our colorectal cancer patients, 302 in total, between 15.03.2019-14.03.2021. The first year's data was considered as the control group and the second one, the study (pandemic) group. Results: We observed a 12% decrease in colorectal cancer hospitalizations in the first year, 38,6% in the first six months. The rate of emergency admissions, colo/ileostomy formatting procedures, palliative resections, clinical metastasis was higher in the pandemic group. More advanced locoregional invasion, a higher tumor stage, higher rate of vascular, perineural invasion, positive resection margin, and a higher lymph node yield was seen after the restrictions were implemented. Conclusion: The COVID-19 pandemic and the response against it had a major effect on the colorectal cancer care in our country. The outcomes of these worse clinical and pathological findings are unknown, but it is important to do further research in this field. We think colorectal cancer care should have an absolute priority in future pandemics.
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The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study
Article
Full-text available
  • Jul 2020
  • LANCET ONCOL
Background Since a national lockdown was introduced across the UK in March, 2020, in response to the COVID-19 pandemic, cancer screening has been suspended, routine diagnostic work deferred, and only urgent symptomatic cases prioritised for diagnostic intervention. In this study, we estimated the impact of delays in diagnosis on cancer survival outcomes in four major tumour types. Methods In this national population-based modelling study, we used linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15–84 years, diagnosed with breast, colorectal, and oesophageal cancer between Jan 1, 2010, and Dec 31, 2010, with follow-up data until Dec 31, 2014, and diagnosed with lung cancer between Jan 1, 2012, and Dec 31, 2012, with follow-up data until Dec 31, 2015. We use a routes-to-diagnosis framework to estimate the impact of diagnostic delays over a 12-month period from the commencement of physical distancing measures, on March 16, 2020, up to 1, 3, and 5 years after diagnosis. To model the subsequent impact of diagnostic delays on survival, we reallocated patients who were on screening and routine referral pathways to urgent and emergency pathways that are associated with more advanced stage of disease at diagnosis. We considered three reallocation scenarios representing the best to worst case scenarios and reflect actual changes in the diagnostic pathway being seen in the NHS, as of March 16, 2020, and estimated the impact on net survival at 1, 3, and 5 years after diagnosis to calculate the additional deaths that can be attributed to cancer, and the total years of life lost (YLLs) compared with pre-pandemic data. Findings We collected data for 32 583 patients with breast cancer, 24 975 with colorectal cancer, 6744 with oesophageal cancer, and 29 305 with lung cancer. Across the three different scenarios, compared with pre-pandemic figures, we estimate a 7·9–9·6% increase in the number of deaths due to breast cancer up to year 5 after diagnosis, corresponding to between 281 (95% CI 266–295) and 344 (329–358) additional deaths. For colorectal cancer, we estimate 1445 (1392–1591) to 1563 (1534–1592) additional deaths, a 15·3–16·6% increase; for lung cancer, 1235 (1220–1254) to 1372 (1343–1401) additional deaths, a 4·8–5·3% increase; and for oesophageal cancer, 330 (324–335) to 342 (336–348) additional deaths, 5·8–6·0% increase up to 5 years after diagnosis. For these four tumour types, these data correspond with 3291–3621 additional deaths across the scenarios within 5 years. The total additional YLLs across these cancers is estimated to be 59 204–63 229 years. Interpretation Substantial increases in the number of avoidable cancer deaths in England are to be expected as a result of diagnostic delays due to the COVID-19 pandemic in the UK. Urgent policy interventions are necessary, particularly the need to manage the backlog within routine diagnostic services to mitigate the expected impact of the COVID-19 pandemic on patients with cancer. Funding UK Research and Innovation Economic and Social Research Council.
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Effect of length of time from diagnosis to treatment on colorectal cancer survival: A population-based study
Article
Full-text available
Evidence is limited regarding the effect of diagnosis-to-treatment interval (DTI) on the survival of colorectal cancer (CRC) patients. In addition, previous studies on treatment delay and CRC survival have largely grouped patients from all stages (I-IV) into one cohort. Our study provides analysis on each stage individually. We conducted a retrospective cohort study with 39,000 newly diagnosed CRC patients obtained from the Taiwan Cancer Registry Database from 2004–2010 to examine the effect of DTIs on overall survival. DTIs were divided into 3 groups: ≤ 30 days (36,115 patients, 90.5% of study patients), 31–150 days (2,533, 6.4%), and ≥ 151 days (1,252, 3.15%). Risk of death was increased for DTI 31–150 days (hazard ratio 1.51; 95% confidence interval 1.43–1.59) and DTI ≥ 151 days (1.64; 1.54–1.76) compared to DTI ≤ 30. This risk was consistent across all cancer stages. Additional factors that increased risk of death include male gender, age >75, Charlson Comorbidity Index ≥7, other catastrophic illnesses, lack of multidisciplinary team involvement, and treatment in a low volume center. From these results, we advise that the DTI for all CRC patients, regardless of cancer staging, should be 30 days or less.
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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
Article
  • Jul 2020
  • LANCET ONCOL
Background During the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2. Methods In this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008–17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013–16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I–III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1–6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred. Findings Across England in 2013–16, an average of 6281 patients with stage I–III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1–3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3–8 after lockdown would result in 401 additional lives and 7332 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0·0 and 0·7 life-years per referred patient, depending on age and tumour type. Interpretation Prompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer. Funding None.
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